Methods for dosing an actriib antagonist and monitoring of treated patients

ABSTRACT

In certain aspects, the present invention provides methods for dosing a patient with an ActRIIb antagonist and methods for managing patients treated with an ActRIIb anatagonist. In certain aspects, the methods involve measuring one or more hematologic parameters in a patient.

RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.16/735,833, filed Jan. 7, 2020, which is a continuation of U.S.application Ser. No. 15/005,874, filed on Jan. 25, 2016 (now abandoned),which is a continuation of Ser. No. 12/459,205 filed on Jun. 26, 2009(now abandoned) which claims the benefit of U.S. Provisional ApplicationNo. 61/133,354, filed on Jun. 26, 2008 (now expired). The specificationsof each of the foregoing applications are incorporated by referenceherein in their entirety.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has beensubmitted electronically in ASCII format and is hereby incorporated byreference in its entirety. Said ASCII copy, created on May 26, 2021, isnamed 1848179-0002-048-105_Seq.txt and is 35,755 bytes in size.

BACKGROUND OF THE INVENTION

The transforming growth factor-beta (TGF-beta) superfamily contains avariety of growth factors that share common sequence elements andstructural motifs. These proteins are known to exert biological effectson a large variety of cell types in both vertebrates and invertebrates.Members of the superfamily perform important functions during embryonicdevelopment in pattern formation and tissue specification and caninfluence a variety of differentiation processes, includingadipogenesis, myogenesis, chondrogenesis, cardiogenesis, hematopoiesis,neurogenesis, and epithelial cell differentiation. The family is dividedinto two general branches: the BMP/GDF and the TGF-beta/Activin/BMP10branches, whose members have diverse, often complementary effects. Bymanipulating the activity of a member of the TGF-beta family, it isoften possible to cause significant physiological changes in anorganism. For example, the Piedmontese and Belgian Blue cattle breedscarry a loss-of-function mutation in the GDF8 (also called myostatin)gene that causes a marked increase in muscle mass. Grobet et al., NatGenet. 1997, 17(1):71-4. Furthermore, in humans, inactive alleles ofGDF8 are associated with increased muscle mass and, reportedly,exceptional strength. Schuelke et al., N Engl J Med 2004, 350:2682-8.

Changes in muscle, bone, cartilage and other tissues may be achieved byagonizing or antagonizing signaling that is mediated by an appropriateTGF-beta family member. It is an object of the present disclosure toprovide alternative methods for administering modulators of the TGF-betasuperfamily to patients.

SUMMARY OF THE INVENTION

In part, the disclosure related to methods for adminstering ActRIIBantagonists to patients in a manner that is appropriate given theeffects that such antagonists can have on a variety of tissues,including red blood cells. In some embodiments, the disclosure providesActRIIb antagonists can increase red blood cell and hemoglobin levelsand also promote muscle growth or bone growth. This dual effect hasparticular advantages in patients that have both anemia and muscle orbone loss, such as many cancer patients (where anemia and muscle losscan be a consequence of the tumor or a consequence of irradiation orchemotherapy), many forms of cachexia, sarcopenia (muscle lossassociated with aging). In particular, the disclosure demonstrates thata soluble form of ActRIIb is effective to increase reticulocyte levelsin vivo, an effect which over a longer time period is expected to causeincreased hematocrit levels. While soluble ActRIIb may affectreticulocyte levels through a mechanism other than ActRIIb antagonism,the disclosure nonetheless demonstrates that desirable therapeuticagents may be selected on the basis of ActRIIb antagonism. The termActRIIb antagonist is used herein to indicate soluble ActRIIbpolypeptides (e.g., ActRIIb-Fc), as well as antibodies and otherantagonists that target ActRIIb or its ligands at the protein or nucleicacid level. As described herein, and in published patent applicationsWO/2009/038745, WO/2008/100384, WO/2008/094708, WO/2008/076437,WO/2007/062188 and WO/2006/012627, ActRIIb antagonists also have avariety of other therapeutic uses including, for example, promoting bonegrowth, or promoting muscle growth. In certain instances, whenadministering an ActRIIb antagonist for promoting bone growth growth orpromoting muscle growth, it may be desirable to monitor the effects onred blood cells during administration of an ActRIIb antagonist, or todetermine or adjust the dosing of an ActRIIb antagonist, in order toreduce undesired effects on red blood cells. For example, excessiveincreases in red blood cell levels, hemoglobin levels, or hematocritlevels may cause increases in blood pressure or other undesirable sideeffects. It may also be desirable to restrict dosing of ActRIIbantagonists to patients who have appropriate hematologic parameters. Forexample, it may be desirable to limit dosing to only those patients whohave a hemoglobin level below normal (e.g., below 12 g/dL, below 11g/dL, below 10 g/dL or below 9 g/dL or lower).

Therefore, in certain embodiments, the disclosure provides methods formanaging a patient that has been treated with, or is a candidate to betreated with, an ActRIIb-antagonist, including, for example, ActRIIbpolypeptides (including those that bind to one or more ActRIIb ligandssuch as activin or myostatin), anti-ActRIIb antibodies, orActRIIb-targeted small molecules and aptamers, and nucleic acids thatdecrease expression of ActRIIb, by monitoring in the patient one or morehematologic parameters that correlate with an increase in red blood celllevels, such as, for example, red blood cell levels, blood pressure, oriron stores.

In certain aspects, the disclosure provides polypeptides comprising asoluble, ligand-binding ActRIIb polypeptide that binds to activin ormyostatin or other ActRIIb ligand. ActRIIb polypeptides may beformulated as a pharmaceutical preparation comprising the ligand-binding(e.g. activin-binding) ActRIIb polypeptide and a pharmaceuticallyacceptable carrier. The ligand-binding ActRIIb polypeptide may bind toactivin with a K_(D) less than 1 micromolar or less than 100, 10 or 1nanomolar. The composition may be at least 95% pure, with respect toother polypeptide components, as assessed by size exclusionchromatography, and optionally, the composition is at least 98% pure. AnActRIIb polypeptide for use in such a preparation may be any of thosedisclosed herein, such as a polypeptide having an amino acid sequenceselected from SEQ ID NOs: 2, 3, 6, 8, or 9 or having an amino acidsequence that is at least 80%, 85%, 90%, 95%, 97% or 99% identical to anamino acid sequence selected from SEQ ID NOs: 2, 3, 6, 8, or 9. Anactive ActRIIb polypeptide may include a functional fragment of anatural ActRIIb polypeptide, such as one comprising at least 10, 20 or30 amino acids of SEQ ID NOs: 1-3 or a sequence lacking the C-terminal10 to 15 amino acids (the “tail”) such as SEQ ID NO: 3.

A soluble, ligand-binding (e.g., activin-binding) ActRIIb polypeptidemay include one or more alterations in the amino acid sequence (e.g., inthe ligand-binding domain) relative to a naturally occurring ActRIIbpolypeptide. Examples of altered ActRIIb polypeptides are provided in WO2006/012627, pp. 59-60 and pp. 55-58, respectively, which isincorporated by reference herein, and throughout U.S. patent applicationSer. No. 12/012,652, incorporated by reference herein. The alteration inthe amino acid sequence may, for example, alter glycosylation of thepolypeptide when produced in a mammalian, insect or other eukaryoticcell or alter proteolytic cleavage of the polypeptide relative to thenaturally occurring ActRIIb polypeptide.

A ligand-binding (e.g., activin-binding) ActRIIb polypeptide may be afusion protein that has, as one domain, an ActRIIb polypeptide, (e.g., aligand-binding portion of an ActRIIb) and one or more additional domainsthat provide a desirable property, such as improved pharmacokinetics,easier purification, targeting to particular tissues, etc. For example,a domain of a fusion protein may enhance one or more of in vivostability, in vivo half life, uptake/administration, tissue localizationor distribution, formation of protein complexes, multimerization of thefusion protein, and/or purification. A ligand-binding ActRIIb fusionprotein may include an immunoglobulin Fc domain (wild-type or mutant) ora serum albumin or other polypeptide portion that provides desirableproperties such as improved pharmacokinetics, improved solubility orimproved stability. In a preferred embodiment, an ActRIIb-Fc fusioncomprises a relatively unstructured linker positioned between the Fcdomain and the extracellular ActRIIb domain. This unstructured linkermay be an artificial sequence of 1, 2, 3, 4 or 5 amino acids or a lengthof between 5 and 15, 20, 30, 50 or more amino acids that are relativelyfree of secondary structure, or a mixture of both. A linker may be richin glycine and proline residues and may, for example, contain a singlesequence of threonine/serine and glycines or repeating sequences ofthreonine/serine and glycines (e.g., TG₄ (SEQ ID NO: 14) or SG₄ (SEQ IDNO: 15) singlets or repeats). A fusion protein may include apurification subsequence, such as an epitope tag, a FLAG tag, apolyhistidine sequence, and a GST fusion. Optionally, a soluble ActRIIbpolypeptide includes one or more modified amino acid residues selectedfrom: a glycosylated amino acid, a PEGylated amino acid, a farnesylatedamino acid, an acetylated amino acid, a biotinylated amino acid, anamino acid conjugated to a lipid moiety, and an amino acid conjugated toan organic derivatizing agent. A pharmaceutical preparation may alsoinclude one or more additional compounds such as a compound that is usedto treat a bone disorder or a compound that is used to treat anemia.Preferably, a pharmaceutical preparation is substantially pyrogen free.In general, it is preferable that an ActRIIb protein be expressed in amammalian cell line that mediates suitably natural glycosylation of theActRIIb protein so as to diminish the likelihood of an unfavorableimmune response in a patient. Human and CHO cell lines have been usedsuccessfully, and it is expected that other common mammalian expressionsystems will be useful.

In some embodiments, ActRIIb proteins designated ActRIIb-Fc havespecific properties, including selective binding to activin versus GDF8and/or GDF11 or vice versa, high affinity ligand binding and serum halflife greater than two weeks in animal models and in human patients. Incertain embodiments the invention provides ActRIIb-Fc polypeptides andpharmaceutical preparations comprising such polypeptides and apharmaceutically acceptable excipient.

In certain aspects, the disclosure provides nucleic acids encoding asoluble ligand-binding ActRIIb polypeptide. An isolated polynucleotidemay comprise a coding sequence for a soluble, ligand-binding (e.g.activin-binding) ActRIIb polypeptide, such as described above. Forexample, an isolated nucleic acid may include a sequence coding for anextracellular domain (e.g., ligand-binding domain) of an ActRIIb and asequence that would code for part or all of the transmembrane domainand/or the cytoplasmic domain of an ActRIIb, but for a stop codonpositioned within the transmembrane domain or the cytoplasmic domain, orpositioned between the extracellular domain and the transmembrane domainor cytoplasmic domain. For example, an isolated polynucleotide maycomprise a full-length ActRIIb polynucleotide sequence such as SEQ IDNO: 4 or a partially truncated version of ActRIIb, such as a nucleicacid comprising the nucleic acid sequence of SEQ ID NO: 5, whichcorresponds to the extracellular domain of ActRIIb. An isolatedpolynucleotide may further comprise a transcription termination codon atleast six hundred nucleotides before the 3′-terminus or otherwisepositioned such that translation of the polynucleotide gives rise to anextracellular domain optionally fused to a truncated portion of afull-length ActRIIb. A preferred nucleic acid sequence for ActRIIb isSEQ ID NO: 10. Nucleic acids disclosed herein may be operably linked toa promoter for expression, and the disclosure provides cells transformedwith such recombinant polynucleotides. Preferably the cell is amammalian cell such as a CHO cell.

In certain aspects, the disclosure provides methods for making asoluble, ligand-binding (e.g. activin-binding) ActRIIb polypeptide. Sucha method may include expressing any of the nucleic acids (e.g., SEQ IDNOs: 4, 5, or 10) disclosed herein in a suitable cell, such as a Chinesehamster ovary (CHO) cellor a human cell. Such a method may comprise: a)culturing a cell under conditions suitable for expression of the solubleActRIIb polypeptide, wherein said cell is transformed with a solubleActRIIb expression construct; and b) recovering the soluble ActRIIbpolypeptide so expressed. Soluble ActRIIb polypeptides may be recoveredas crude, partially purified or highly purified fractions. Purificationmay be achieved by a series of purification steps, including, forexample, one, two or three or more of the following, in any order:protein A chromatography, anion exchange chromatography (e.g., Qsepharose), hydrophobic interaction chromatography (e.g.,phenylsepharose), size exclusion chromatography, and cation exchangechromatography. Soluble ActRIIb polypeptides may be formulated in liquidor solid (e.g., lyophilized) forms.

In certain aspects, the disclosure provides a method for dosing apatient with an activin-ActRIIb antagonist, comprising dosing thepatient in amounts and at intervals selected so as to reduce the risk ofcausing a rise in hemoglobin levels greater than 0.5 g/dL, 1 g/dl or 1.5g/dL in two weeks.

In certain aspects, the disclosure provides a method for administeringan ActRIIb-Fc fusion protein to a patient, comprising administering theActRIIb fusion protein no more frequently than once per 60 days, onceper 90 days, or once per 120 days. In certain embodiments, the patientmay be a patient in need of bone growth or muscle growth.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows an alignement of human ActRIIA and ActRIIB with theresidues that are deduced herein, based on composite analysis ofmultiple ActRIIB and ActRIIA crystal structures to directly contactligand (the ligand pocket) indicated with boxes.

DETAILED DESCRIPTION OF THE INVENTION 1. Overview

The transforming growth factor-beta (TGF-beta) superfamily contains avariety of growth factors that share common sequence elements andstructural motifs. These proteins are known to exert biological effectson a large variety of cell types in both vertebrates and invertebrates.Members of the superfamily perform important functions during embryonicdevelopment in pattern formation and tissue specification and caninfluence a variety of differentiation processes, includingadipogenesis, myogenesis, chondrogenesis, cardiogenesis, hematopoiesis,neurogenesis, and epithelial cell differentiation. The family is dividedinto two general branches: the BMP/GDF and the TGF-beta/Activin/BMP10branches, whose members have diverse, often complementary effects. Bymanipulating the activity of a member of the TGF-beta family, it isoften possible to cause significant physiological changes in anorganism. For example, the Piedmontese and Belgian Blue cattle breedscarry a loss-of-function mutation in the GDF8 (also called myostatin)gene that causes a marked increase in muscle mass. Grobet et al., NatGenet. 1997, 17(1):71-4. Furthermore, in humans, inactive alleles ofGDF8 are associated with increased muscle mass and, reportedly,exceptional strength. Schuelke et al., N Engl J Med 2004, 350:2682-8.

Activins are dimeric polypeptide growth factors that belong to theTGF-beta superfamily. There are three principal activin forms (A, B, andAB) that are homo/heterodimers of two closely related β subunits(β_(A)β_(A), β_(B)β_(B), and β_(A)β_(B), respectively). The human genomealso encodes an activin C and an activin E, which are primarilyexpressed in the liver, and heterodimeric forms containing β_(C) orβ_(E) are also known. In the TGF-beta superfamily, activins are uniqueand multifunctional factors that can stimulate hormone production inovarian and placental cells, support neuronal cell survival, influencecell-cycle progress positively or negatively depending on cell type, andinduce mesodermal differentiation at least in amphibian embryos (DePaoloet al., 1991, Proc Soc Ep Biol Med. 198:500-512; Dyson et al., 1997,Curr Biol. 7:81-84; Woodruff, 1998, Biochem Pharmacol. 55:953-963).Moreover, erythroid differentiation factor (EDF) isolated from thestimulated human monocytic leukemic cells was found to be identical toactivin A (Murata et al., 1988, PNAS, 85:2434). It has been suggestedthat activin A promotes erythropoiesis in the bone marrow. In severaltissues, activin signaling is antagonized by its related heterodimer,inhibin. For example, during the release of follicle-stimulating hormone(FSH) from the pituitary, activin promotes FSH secretion and synthesis,while inhibin prevents FSH secretion and synthesis. Other proteins thatmay regulate activin bioactivity and/or bind to activin includefollistatin (FS), follistatin-related protein (FSRP) andα₂-macroglobulin.

TGF-β signals are mediated by heteromeric complexes of type I and typeII serine/threonine kinase receptors, which phosphorylate and activatedownstream Smad proteins upon ligand stimulation (Massagué, 2000, Nat.Rev. Mol. Cell Biol. 1:169-178). These type I and type II receptors aretransmembrane proteins, composed of a ligand-binding extracellulardomain with cysteine-rich region, a transmembrane domain, and acytoplasmic domain with predicted serine/threonine specificity. Type Ireceptors are essential for signaling; and type II receptors arerequired for binding ligands and for expression of type I receptors.Type I and II activin receptors form a stable complex after ligandbinding, resulting in phosphorylation of type I receptors by type IIreceptors.

Two related type II receptors (ActRII), ActRIIa and ActRIIb, have beenidentified as the type II receptors for activins (Mathews and Vale,1991, Cell 65:973-982; Attisano et al., 1992, Cell 68: 97-108). Besidesactivins, ActRIIa and ActRIIb can biochemically interact with severalother TGF-β family proteins, including BMP7, Nodal, GDF8, and GDF11(Yamashita et al., 1995, J. Cell Biol. 130:217-226; Lee and McPherron,2001, Proc. Natl. Acad. Sci. 98:9306-9311; Yeo and Whitman, 2001, Mol.Cell 7: 949-957; Oh et al., 2002, Genes Dev. 16:2749-54). ALK4 is theprimary type I receptor for activins, particularly for activin A, andALK-7 may serve as a receptor for activins as well, particularly foractivin B.

As demonstrated herein, a soluble ActRIIb polypeptide (sActRIIb) iseffective to increase reticulocyte levels in vivo, an effect which, overa longer time period is expected to cause increased hematocrit levels.Increases were observed in rodents with longer exposure. Thus, in someembodiments, sActRIIb polypeptides of the disclosure may be usedincrease red blood cell levels in vivo. Regardless of mechanism, it isapparent from this disclosure that ActRIIb antagonists stimulateerythropoiesis in rodents and monkeys. It should be noted thathematopoiesis is a complex process, regulated by a variety of factors,including erythropoietin, G-CSF and iron homeostasis. The terms“increase red blood cell levels” and “promote red blood cell formation”refer to clinically observable metrics, such as hematocrit, red bloodcell counts and hemoglobin measurements, and are intended to be neutralas to the mechanism by which such changes occur.

In addition to stimulating red blood cell levels, certain ActRIIbantagonists are useful for a variety of therapeutic applications,including, for example, promoting bone growth (see PCT Publication WO2006/012627, which is hereby incorporated by reference in its entirety)and promoting muscle growth (see PCT Publication No. WO2006/012627 andPCT Application No. PCT/US2008/001506, which are hereby incorporated byreference in their entirety). In certain instances, when administeringan ActRIIb antagonist for the purpose of increasing muscle or bone, itmay be desirable to reduce or minimize or otherwise monitor effects onred blood cells. In some instances, a dual effect on blood cells andmuscle, bone or other tissue will be desirable, but it is generallyrecognized that pharmaceutically promoted increases in red blood cells,even up to a level that is typically considered normal, can have adverseeffects on patients, and thus are often monitored or managed with care.By monitoring various hematologic parameters in patients being treatedwith, or who are candidates for treatment with, an ActRIIb antagonist,appropriate dosing (including amounts and frequency of administration)may be determined based on an individual patient's needs, baselinehematologic parameters, and purpose for treatment. Furthermore,therapeutic progress and effects on one or more hematologic parametersover time may be useful in managing patients being dosed with an ActRIIbantagonist by facilitating patient care, determining appropriatemaintenance dosing (both amounts and frequency), etc.

ActRIIb antagonists include, for example, ligand-binding (e.g.activin-binding) soluble ActRIIb polypeptides, antibodies that bind toActRIIb and disrupt activin binding, non-antibody proteins selected forActRIIb binding (see e.g., WO/2002/088171, WO/2006/055689, andWO/2002/032925 for examples of such proteins and methods for design andselection of same), randomized peptides selected for ActRIIb binding,often affixed to an Fc domain. Two different proteins (or othermoieties) with ActRIIb binding activity may be linked together to createa bifunctional binding molecule. Nucleic acid aptamers, small moleculesand other agents that inhibit the ActRIIb signaling axis are included asActRIIb antagonists. Various proteins have antagonist that may besimilar to ActRIIb antagonists, including inhibin (i.e., inhibin alphasubunit), although inhibin does not universally antagonize activin inall tissues, follistatin (e.g., follistatin-288 and follistatin-315),FSRP, FLRG, activin C, alpha(2)-macroglobulin, and an M108A (methionineto alanine change at position 108) mutant activin A. Generally,alternative forms of activin, particularly those with alterations in thetype I receptor binding domain can bind to type II receptors and fail toform an active ternary complex, thus acting as antagonists.Additionally, nucleic acids, such as antisense molecules, siRNAs orribozymes that inhibit ActRIIb expression, can be used as ActRIIbantagonists. The ActRIIb antagonist to be used may exhibit selectivityfor inhibiting activin-mediated signaling versus other members of theTGF-beta family, and particularly with respect to GDF8 and GDF11.

The terms used in this specification generally have their ordinarymeanings in the art, within the context of this invention and in thespecific context where each term is used. Certain terms are discussedbelow or elsewhere in the specification, to provide additional guidanceto the practitioner in describing the compositions and methods of theinvention and how to make and use them. The scope or meaning of any useof a term will be apparent from the specific context in which the termis used.

“About” and “approximately” shall generally mean an acceptable degree oferror for the quantity measured given the nature or precision of themeasurements. Typically, exemplary degrees of error are within 20percent (%), preferably within 10%, and more preferably within 5% of agiven value or range of values.

Alternatively, and particularly in biological systems, the terms “about”and “approximately” may mean values that are within an order ofmagnitude, preferably within 5-fold and more preferably within 2-fold ofa given value. Numerical quantities given herein are approximate unlessstated otherwise, meaning that the term “about” or “approximately” canbe inferred when not expressly stated.

The methods of the invention may include steps of comparing sequences toeach other, including wild-type sequence to one or more mutants(sequence variants). Such comparisons typically comprise alignments ofpolymer sequences, e.g., using sequence alignment programs and/oralgorithms that are well known in the art (for example, BLAST, FASTA andMEGALIGN, to name a few). The skilled artisan can readily appreciatethat, in such alignments, where a mutation contains a residue insertionor deletion, the sequence alignment will introduce a “gap” (typicallyrepresented by a dash, or “A”) in the polymer sequence not containingthe inserted or deleted residue.

“Homologous,” in all its grammatical forms and spelling variations,refers to the relationship between two proteins that possess a “commonevolutionary origin,” including proteins from superfamilies in the samespecies of organism, as well as homologous proteins from differentspecies of organism. Such proteins (and their encoding nucleic acids)have sequence homology, as reflected by their sequence similarity,whether in terms of percent identity or by the presence of specificresidues or motifs and conserved positions.

The term “sequence similarity,” in all its grammatical forms, refers tothe degree of identity or correspondence between nucleic acid or aminoacid sequences that may or may not share a common evolutionary origin.

However, in common usage and in the instant application, the term“homologous,” when modified with an adverb such as “highly,” may referto sequence similarity and may or may not relate to a commonevolutionary origin.

2. ActRIIb Polypeptides

In certain aspects, the present invention relates to ActRIIbpolypeptides. As used herein, the term “ActRIIb” refers to a family ofactivin receptor type IIb (ActRIIb) proteins from any species andvariants derived from such ActRIIb proteins by mutagenesis or othermodification. Reference to ActRIIb herein is understood to be areference to any one of the currently identified forms. Members of theActRIIb family are generally transmembrane proteins, composed of aligand-binding extracellular domain with a cysteine-rich region, atransmembrane domain, and a cytoplasmic domain with predictedserine/threonine kinase activity.

In certain aspects, the present invention relates to ActRIIbpolypeptides. As used herein, the term “ActRIIb” refers to a family ofactivin receptor type IIb (ActRIIb) proteins from any species andvariants derived from such ActRIIb proteins by mutagenesis or othermodification. Reference to ActRIIb herein is understood to be areference to any one of the currently identified forms. Members of theActRIIb family are generally transmembrane proteins, composed of aligand-binding extracellular domain with a cysteine-rich region, atransmembrane domain, and a cytoplasmic domain with predictedserine/threonine kinase activity.

The term “ActRIIb polypeptide” includes polypeptides comprising anynaturally occurring polypeptide of an ActRIIb family member as well asany variants thereof (including mutants, fragments, fusions, andpeptidomimetic forms) that retain a useful activity. See, for example,WO/2006/012627 and WO/2008/097541. For example, ActRIIb polypeptidesinclude polypeptides derived from the sequence of any known ActRIIbhaving a sequence at least about 80% identical to the sequence of anActRIIb polypeptide, and optionally at least 85%, 90%, 95%, 97%, 99% orgreater identity. For example, an ActRIIb_polypeptide of the inventionmay bind to and inhibit the function of an ActRIIb protein and/oractivin. An ActRIIb polypeptide may be selected for activity inpromoting red blood cell formation in vivo. Examples of ActRIIbpolypeptides include human ActRIIb precursor polypeptide (SEQ ID NO: 1)and soluble human ActRIIb polypeptides (e.g., SEQ ID NO: 2, 3, 8, and9).

The human ActRIIb precursor protein sequence is as follows:

(SEQ ID NO: 1)

YDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTLLTVLAYSLLPIGGLSLIVLLAFWMYRHRKPPYGHVDIHEDPGPPPPSPLVGLKPLQLLEIKARGRFGCVWKAQLMNDFVAVKIFPLQDKQSWQSEREIFSTPGMKHENLLQFIAAEKRGSNLEVELWLITAFHDKGSLTDYLKGNIITWNELCHVAETMSRGLSYLHEDVPWCRGEGHKPSIAHRDFKSKNVLLKSDLTAVLADFGLAVRFEPGKPPGDTHGQVGTRRYMAPEVLEGAINFQRDAFLRIDMYAMGLVLWELVSRCKAADGPVDEYMLPFEEEIGQHPSLEELQEVVHKKMRPTIKDHWLKHPGLAQLCVTIEECWDHDAEARLSAGCVEERVSLIRRSVNGTTSDCLVSLVTSVTNVDL PPKESSI 

The signal peptide is single underlined; the extracellular domain is inbold and the potential N-linked glycosylation sites are in boxes.

The human ActRIIb soluble (extracellular), processed polypeptidesequence is as follows:

(SEQ ID NO: 2) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWANSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLP EAGGPEVTYEPPPTAPT

In some conditions, the protein may be produced with an “SGR . . . ”sequence at the N-terminus. The C-terminal “tail” of the extracellulardomain is underlined. The sequence with the “tail” deleted (a Δ15sequence) is as follows:

(SEQ ID NO: 3) GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWANSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLP EA

In some conditions, the protein may be produced with an “SGR . . . ”sequence at the N-terminus. The nucleic acid sequence encoding a humanActRIIb precursor protein is as follows: (nucleotides 5-1543 of Genbankentry NM_001106)

(SEQ ID NO: 4) ATGACGGCGCCCTGGGTGGCCCTCGCCCTCCTCTGGGGATCGCTGTGGCCCGGCTCTGGGCGTGGGGAGGCTGAGACACGGGAGTGCATCTACTACAACGCCAACTGGGAGCTGGAGCGCACCAACCAGAGCGGCCTGGAGCGCTGCGAAGGCGAGCAGGACAAGCGGCTGCACTGCTACGCCTCCTGGGCCAACAGCTCTGGCACCATCGAGCTCGTGAAGAAGGGCTGCTGGCTAGATGACTTCAACTGCTACGATAGGCAGGAGTGTGTGGCCACTGAGGAGAACCCCCAGGTGTACTTCTGCTGCTGTGAAGGCAACTTCTGCAACGAGCGCTTCACTCATTTGCCAGAGGCTGGGGGCCCGGAAGTCACGTACGAGCCACCCCCGACAGCCCCCACCCTGCTCACGGTGCTGGCCTACTCACTGCTGCCCATCGGGGGCCTTTCCCTCATCGTCCTGCTGGCCTTTTGGATGTACCGGCATCGCAAGCCCCCCTACGGTCATGTGGACATCCATGAGGACCCTGGGCCTCCACCACCATCCCCTCTGGTGGGCCTGAAGCCACTGCAGCTGCTGGAGATCAAGGCTCGGGGGCGCTTTGGCTGTGTCTGGAAGGCCCAGCTCATGAATGACTTTGTAGCTGTCAAGATCTTCCCACTCCAGGACAAGCAGTCGTGGCAGAGTGAACGGGAGATCTTCAGCACACCTGGCATGAAGCACGAGAACCTGCTACAGTTCATTGCTGCCGAGAAGCGAGGCTCCAACCTCGAAGTAGAGCTGTGGCTCATCACGGCCTTCCATGACAAGGGCTCCCTCACGGATTACCTCAAGGGGAACATCATCACATGGAACGAACTGTGTCATGTAGCAGAGACGATGTCACGAGGCCTCTCATACCTGCATGAGGATGTGCCCTGGTGCCGTGGCGAGGGCCACAAGCCGTCTATTGCCCACAGGGACTTTAAAAGTAAGAATGTATTGCTGAAGAGCGACCTCACAGCCGTGCTGGCTGACTTTGGCTTGGCTGTTCGATTTGAGCCAGGGAAACCTCCAGGGGACACCCACGGACAGGTAGGCACGAGACGGTACATGGCTCCTGAGGTGCTCGAGGGAGCCATCAACTTCCAGAGAGATGCCTTCCTGCGCATTGACATGTATGCCATGGGGTTGGTGCTGTGGGAGCTTGTGTCTCGCTGCAAGGCTGCAGACGGACCCGTGGATGAGTACATGCTGCCCTTTGAGGAAGAGATTGGCCAGCACCCTTCGTTGGAGGAGCTGCAGGAGGTGGTGGTGCACAAGAAGATGAGGCCCACCATTAAAGATCACTGGTTGAAACACCCGGGCCTGGCCCAGCTTTGTGTGACCATCGAGGAGTGCTGGGACCATGATGCAGAGGCTCGCTTGTCCGCGGGCTGTGTGGAGGAGCGGGTGTCCCTGATTCGGAGGTCGGTCAACGGCACTACCTCGGACTGTCTCGTTTCCCTGGTGACCTCTGTCACCAATGTGGACCTGCCCC CTAAAGAGTCAAGCATCTAA

The nucleic acid sequence encoding a human ActRIIb soluble(extracellular) polypeptide is as follows:

(SEQ ID NO: 5) TCTGGGCGTGGGGAGGCTGAGACACGGGAGTGCATCTACTACAACGCCAACTGGGAGCTGGAGCGCACCAACCAGAGCGGCCTGGAGCGCTGCGAAGGCGAGCAGGACAAGCGGCTGCACTGCTACGCCTCCTGGGCCAACAGCTCTGGCACCATCGAGCTCGTGAAGAAGGGCTGCTGGCTAGATGACTTCAACTGCTACGATAGGCAGGAGTGTGTGGCCACTGAGGAGAACCCCCAGGTGTACTTCTGCTGCTGTGAAGGCAACTTCTGCAACGAGCGCTTCACTCATTTGCCAGAGGCTGGGGGCCCGGAAGTCACGTACGAGCCACCCCCGACAGCCC CCACC

In a specific embodiment, the invention relates to soluble ActRIIbpolypeptides. As described herein, the term “soluble ActRIIbpolypeptide” generally refers to polypeptides comprising anextracellular domain of an ActRIIb protein. The term “soluble ActRIIbpolypeptide,” as used herein, includes any naturally occurringextracellular domain of an ActRIIb protein as well as any variantsthereof (including mutants, fragments and peptidomimetic forms). Aligand-binding (e.g. activin-binding) ActRIIb polypeptide is one thatretains the ability to bind to activin, including, for example, activinAA, AB, BB, or forms that include a C or E subunit. Optionally, aligand-binding (e.g. activin-binding) ActRIIb polypeptide will bind toactivin AA with a dissociation constant of 1 nM or less. Theextracellular domain of an ActRIIb protein binds to activin and otherligands, such as myostatin, and is generally soluble in physiologicalconditions, and thus can be termed a soluble, ligand-binding (e.g.activin-binding) ActRIIb polypeptide. Examples of soluble,ligand-binding (e.g. activin-binding) ActRIIb polypeptides include thesoluble polypeptides illustrated in SEQ ID NOs: 2, 3, 8, and 9. SEQ IDNO: 8 is referred to as ActRIIb-hFc, and is described further in theExamples. Other examples of soluble, ligand-binding (e.g.activin-binding) ActRIIb polypeptides comprise a signal sequence inaddition to the extracellular domain of an ActRIIb protein, for example,the honey bee mellitin leader sequence (SEQ ID NO: 11), the tissueplaminogen activator (TPA) leader (SEQ ID NO: 12) or the native ActRIIbleader (SEQ ID NO: 13). The ActRIIb-hFc polypeptide illustrated in SEQID NO: 9 uses a TPA leader.

Extensive analysis of structure function analysis of ActRIIb is providedin U.S. patent application Ser. No. 12/012,652, which analysis isincorporated by reference herein. FIG. 1 shows amino acids that areinvolved in the ligand binding domain. ActRIIb residues likely to be incontact with ligands in the binding pocket have been defined. At thesepositions, it is expected that conservative mutations will be tolerated,although a K74A mutation is well-tolerated, as are R40A, K55A, F82A andmutations at position L79. R40 is a K in Xenopus, indicating that basicamino acids at this position will be tolerated. Q53 is R in bovineActRIIB and K in Xenopus ActRIIB, and therefore amino acids including R,K, Q, N and H will be tolerated at this position. Outside of theseresidues, it is expected that modifications will be relativelywell-tolerated, provided that such alterations do not disrupt thestructure of the protein as a whole. It is readily apparent when aprotein structure is disrupted because the protein will tend to expresspoorly or be degraded in the culture media. Thus, a general formula foran active ActRIIb variant protein is one that comprises amino acids12-82 of SEQ ID No. 2 respectively, but optionally beginning at aposition ranging from 1-5 or 3-5 and ending at a position ranging from110-116 or 110-115, respectively, and comprising no more than 1, 2, 5,10 or 15 conservative amino acid changes in the ligand binding pocket,and zero, one or more non-conservative alterations at positions 40, 53,55, 74, 79 and/or 82 in the ligand binding pocket. Such a protein maycomprise an amino acid sequence that retains greater than 80%, 90%, 95%or 99% sequence identity to the sequence of amino acids 29-109 of SEQ IDNO: 2.

Functionally active fragments of ActRIIb polypeptides can be obtained byscreening polypeptides recombinantly produced from the correspondingfragment of the nucleic acid encoding an ActRIIb polypeptide. Inaddition, fragments can be chemically synthesized using techniques knownin the art such as conventional Merrifield solid phase f-Moc or t-Bocchemistry. The fragments can be produced (recombinantly or by chemicalsynthesis) and tested to identify those peptidyl fragments that canfunction as antagonists (inhibitors) of ActRIIb protein or signalingmediated by activin.

Functionally active variants of ActRIIb polypeptides can be obtained byscreening libraries of modified polypeptides recombinantly produced fromthe corresponding mutagenized nucleic acids encoding an ActRIIbpolypeptide. The variants can be produced and tested to identify thosethat can function as antagonists (inhibitors) of ActRIIb protein orsignaling mediated by activin. In certain embodiments, a functionalvariant of the ActRIIb polypeptides comprises an amino acid sequencethat is at least 75% identical to an amino acid sequence selected fromSEQ ID NOs: 2 or 3. In certain cases, the functional variant has anamino acid sequence at least 80%, 85%, 90%, 95%, 97%, 98%, 99% or 100%identical to an amino acid sequence selected from SEQ ID NOs: 2 or 3.

Functional variants may be generated by modifying the structure of anActRIIb polypeptide for such purposes as enhancing therapeutic efficacy,or stability (e.g., ex vivo shelf life and resistance to proteolyticdegradation in vivo). Such modified ActRIIb polypeptides when selectedto retain activin binding, are considered functional equivalents of thenaturally-occurring ActRIIb polypeptides. Modified ActRIIb polypeptidescan also be produced, for instance, by amino acid substitution,deletion, or addition. For instance, it is reasonable to expect that anisolated replacement of a leucine with an isoleucine or valine, anaspartate with a glutamate, a threonine with a serine, or a similarreplacement of an amino acid with a structurally related amino acid(e.g., conservative mutations) will not have a major effect on thebiological activity of the resulting molecule. Conservative replacementsare those that take place within a family of amino acids that arerelated in their side chains. Whether a change in the amino acidsequence of an ActRIIb polypeptide results in a functional homolog canbe readily determined by assessing the ability of the variant ActRIIbpolypeptide to produce a response in cells in a fashion similar to thewild-type ActRIIb polypeptide.

In certain embodiments, the present invention contemplates specificmutations of the ActRIIb polypeptides so as to alter the glycosylationof the polypeptide. Such mutations may be selected so as to introduce oreliminate one or more glycosylation sites, such as O-linked or N-linkedglycosylation sites. Asparagine-linked glycosylation recognition sitesgenerally comprise a tripeptide sequence, asparagine-X-threonine orasparagine-X-serine (where “X” is any amino acid) which is specificallyrecognized by appropriate cellular glycosylation enzymes. The alterationmay also be made by the addition of, or substitution by, one or moreserine or threonine residues to the sequence of the wild-type ActRIIbpolypeptide (for O-linked glycosylation sites). A variety of amino acidsubstitutions or deletions at one or both of the first or third aminoacid positions of a glycosylation recognition site (and/or amino aciddeletion at the second position) results in non-glycosylation at themodified tripeptide sequence. Another means of increasing the number ofcarbohydrate moieties on an ActRIIb polypeptide is by chemical orenzymatic coupling of glycosides to the ActRIIb polypeptide. Dependingon the coupling mode used, the sugar(s) may be attached to (a) arginineand histidine; (b) free carboxyl groups; (c) free sulfhydryl groups suchas those of cysteine; (d) free hydroxyl groups such as those of serine,threonine, or hydroxyproline; (e) aromatic residues such as those ofphenylalanine, tyrosine, or tryptophan; or (f) the amide group ofglutamine. Removal of one or more carbohydrate moieties present on anActRIIb polypeptide may be accomplished chemically and/or enzymatically.Chemical deglycosylation may involve, for example, exposure of theActRIIb polypeptide to the compound trifluoromethanesulfonic acid, or anequivalent compound. This treatment results in the cleavage of most orall sugars except the linking sugar (N-acetylglucosamine orN-acetylgalactosamine), while leaving the amino acid sequence intact.Enzymatic cleavage of carbohydrate moieties on ActRIIb polypeptides canbe achieved by the use of a variety of endo- and exo-glycosidases asdescribed by Thotakura et al. (1987) Meth. Enzymol. 138:350. Thesequence of an ActRIIb polypeptide may be adjusted, as appropriate,depending on the type of expression system used, as mammalian, yeast,insect and plant cells may all introduce differing glycosylationpatterns that can be affected by the amino acid sequence of the peptide.In general, ActRIIb proteins for use in humans may be expressed in amammalian cell line that provides proper glycosylation, such as HEK293or CHO cell lines, although other mammalian expression cell lines areexpected to be useful as well. Other non-mammalian cell lines may beused (e.g., yeast, E. coli, insect cells), and in some cases, such celllines may be engineered to include enzymes that confer mammalian-typeglycosylation patterns on the expressed proteins.

This disclosure further contemplates a method of generating mutants,particularly sets of combinatorial mutants of an ActRIIb polypeptide, aswell as truncation mutants; pools of combinatorial mutants areespecially useful for identifying functional variant sequences. Thepurpose of screening such combinatorial libraries may be to generate,for example, ActRIIb polypeptide variants which bind to activin or otherligands. A variety of screening assays are provided below, and suchassays may be used to evaluate variants. For example, an ActRIIbpolypeptide variant may be screened for ability to bind to an ActRIIbligand, to prevent binding of an ActRIIb ligand to an ActRIIbpolypeptide or to interfere with signaling caused by an ActRIIb ligand.

The activity of an ActRIIb polypeptide or its variants may also betested in a cell-based or in vivo assay. For example, the effect of anActRIIb polypeptide variant on the expression of genes involved inhematopoiesis may be assessed. This may, as needed, be performed in thepresence of one or more recombinant ActRIIb ligand proteins (e.g.,activin), and cells may be transfected so as to produce an ActRIIbpolypeptide and/or variants thereof, and optionally, an ActRIIb ligand.Likewise, an ActRIIb polypeptide may be administered to a mouse or otheranimal, and one or more blood measurements, such as an RBC count,hemoglobin, or reticulocyte count may be assessed.

Combinatorially-derived variants can be generated which have a selectiveor generally increased potency relative to a naturally occurring ActRIIbpolypeptide. Likewise, mutagenesis can give rise to variants which haveintracellular half-lives dramatically different than the corresponding awild-type ActRIIb polypeptide. For example, the altered protein can berendered either more stable or less stable to proteolytic degradation orother cellular processes which result in destruction of, or otherwiseinactivation of a native ActRIIb polypeptide. Such variants, and thegenes which encode them, can be utilized to alter ActRIIb polypeptidelevels by modulating the half-life of the ActRIIb polypeptides. Forinstance, a short half-life can give rise to more transient biologicaleffects and, when part of an inducible expression system, can allowtighter control of recombinant ActRIIb polypeptide levels within thecell. In an Fc fusion protein, mutations may be made in the linker (ifany) and/or the Fc portion to alter the half-life of the protein.

A combinatorial library may be produced by way of a degenerate libraryof genes encoding a library of polypeptides which each include at leasta portion of potential ActRIIb polypeptide sequences. For instance, amixture of synthetic oligonucleotides can be enzymatically ligated intogene sequences such that the degenerate set of potential ActRIIbpolypeptide nucleotide sequences are expressible as individualpolypeptides, or alternatively, as a set of larger fusion proteins(e.g., for phage display).

There are many ways by which the library of potential homologs can begenerated from a degenerate oligonucleotide sequence. Chemical synthesisof a degenerate gene sequence can be carried out in an automatic DNAsynthesizer, and the synthetic genes can then be ligated into anappropriate vector for expression. The synthesis of degenerateoligonucleotides is well known in the art (see for example, Narang, S A(1983) Tetrahedron 39:3; Itakura et al., (1981) Recombinant DNA, Proc.3rd Cleveland Sympos. Macromolecules, ed. AG Walton, Amsterdam: Elsevierpp 273-289; Itakura et al., (1984) Annu. Rev. Biochem. 53:323; Itakuraet al., (1984) Science 198:1056; Ike et al., (1983) Nucleic Acid Res.11:477). Such techniques have been employed in the directed evolution ofother proteins (see, for example, Scott et al., (1990) Science249:386-390; Roberts et al., (1992) PNAS USA 89:2429-2433; Devlin etal., (1990) Science 249: 404-406; Cwirla et al., (1990) PNAS USA 87:6378-6382; as well as U.S. Pat. Nos. 5,223,409, 5,198,346, and5,096,815).

Alternatively, other forms of mutagenesis can be utilized to generate acombinatorial library. For example, ActRIIb polypeptide variants can begenerated and isolated from a library by screening using, for example,alanine scanning mutagenesis and the like (Ruf et al., (1994)Biochemistry 33:1565-1572; Wang et al., (1994) J. Biol. Chem.269:3095-3099; Balint et al., (1993) Gene 137:109-118; Grodberg et al.,(1993) Eur. J. Biochem. 218:597-601; Nagashima et al., (1993) J. Biol.Chem. 268:2888-2892; Lowman et al., (1991) Biochemistry 30:10832-10838;and Cunningham et al., (1989) Science 244:1081-1085), by linker scanningmutagenesis (Gustin et al., (1993) Virology 193:653-660; Brown et al.,(1992) Mol. Cell Biol. 12:2644-2652; McKnight et al., (1982) Science232:316); by saturation mutagenesis (Meyers et al., (1986) Science232:613); by PCR mutagenesis (Leung et al., (1989) Method Cell Mol Biol1:11-19); or by random mutagenesis, including chemical mutagenesis, etc.(Miller et al., (1992) A Short Course in Bacterial Genetics, CSHL Press,Cold Spring Harbor, N.Y.; and Greener et al., (1994) Strategies in MolBiol 7:32-34). Linker scanning mutagenesis, particularly in acombinatorial setting, is an attractive method for identifying truncated(bioactive) forms of ActRIIb polypeptides.

A wide range of techniques are known in the art for screening geneproducts of combinatorial libraries made by point mutations andtruncations, and, for that matter, for screening cDNA libraries for geneproducts having a certain property. Such techniques will be generallyadaptable for rapid screening of the gene libraries generated by thecombinatorial mutagenesis of ActRIIb polypeptides. The most widely usedtechniques for screening large gene libraries typically comprisescloning the gene library into replicable expression vectors,transforming appropriate cells with the resulting library of vectors,and expressing the combinatorial genes under conditions in whichdetection of a desired activity facilitates relatively easy isolation ofthe vector encoding the gene whose product was detected. Preferredassays include activin binding assays and activin-mediated cellsignaling assays.

In certain embodiments, the ActRIIb polypeptides of the invention mayfurther comprise post-translational modifications in addition to anythat are naturally present in the ActRIIb polypeptides. Suchmodifications include, but are not limited to, acetylation,carboxylation, glycosylation, phosphorylation, lipidation, andacylation. As a result, the modified ActRIIb polypeptides may containnon-amino acid elements, such as polyethylene glycols, lipids, poly- ormono-saccharide, and phosphates. Effects of such non-amino acid elementson the functionality of an ActRIIb polypeptide may be tested asdescribed herein for other ActRIIb polypeptide variants. When an ActRIIbpolypeptide is produced in cells by cleaving a nascent form of theActRIIb polypeptide, post-translational processing may also be importantfor correct folding and/or function of the protein. Different cells(such as CHO, HeLa, MDCK, 293, WI38, NIH-3T3 or HEK293) have specificcellular machinery and characteristic mechanisms for suchpost-translational activities and may be chosen to ensure the correctmodification and processing of the ActRIIb polypeptides.

In certain aspects, functional variants or modified forms of the ActRIIbpolypeptides include fusion proteins having at least a portion of theActRIIb polypeptides and one or more fusion domains. Well known examplesof such fusion domains include, but are not limited to, polyhistidine,Glu-Glu, glutathione S transferase (GST), thioredoxin, protein A,protein G, an immunoglobulin heavy chain constant region (Fc), maltosebinding protein (MBP), or human serum albumin. A fusion domain may beselected so as to confer a desired property. For example, some fusiondomains are particularly useful for isolation of the fusion proteins byaffinity chromatography. For the purpose of affinity purification,relevant matrices for affinity chromatography, such as glutathione-,amylase-, and nickel- or cobalt-conjugated resins are used. Many of suchmatrices are available in “kit” form, such as the Pharmacia GSTpurification system and the QIAexpress™ system (Qiagen) useful with(HIS6) fusion partners. As another example, a fusion domain may beselected so as to facilitate detection of the ActRIIb polypeptides.Examples of such detection domains include the various fluorescentproteins (e.g., GFP) as well as “epitope tags,” which are usually shortpeptide sequences for which a specific antibody is available. Well knownepitope tags for which specific monoclonal antibodies are readilyavailable include FLAG, influenza virus haemagglutinin (HA), and c-myctags. In some cases, the fusion domains have a protease cleavage site,such as for Factor Xa or Thrombin, which allows the relevant protease topartially digest the fusion proteins and thereby liberate therecombinant proteins therefrom. The liberated proteins can then beisolated from the fusion domain by subsequent chromatographicseparation. In certain preferred embodiments, an ActRIIb polypeptide isfused with a domain that stabilizes the ActRIIb polypeptide in vivo (a“stabilizer” domain). By “stabilizing” is meant anything that increasesserum half life, regardless of whether this is because of decreaseddestruction, decreased clearance by the kidney, or other pharmacokineticeffect. Fusions with the Fc portion of an immunoglobulin are known toconfer desirable pharmacokinetic properties on a wide range of proteins.Constant domains from an immunoglobulin, particularly an IgG heavychain, may also be used as stabilizing domains. Likewise, fusions tohuman serum albumin can confer desirable properties. Other types offusion domains that may be selected include multimerizing (e.g.,dimerizing, tetramerizing) domains and functional domains (that conferan additional biological function, such as further stimulation of musclegrowth).

An example of an IgG1 Fc domain is shown below (SEQ ID NO: 7).

THTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVD(A)VSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCK(A)VSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGPFFLYSKLTVDKSRWQQGNVFSCSVMHEALHN(A)HYTQKSLSLSPGK*

As an additional specific example, the present invention provides afusion protein comprising a soluble extracellular domain of ActRIIbfused to an Fc domain (Fc portion underlined) (e.g., SEQ ID NO: 6).

SGRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDENCYDRQECVATEENPQVYFCCCEGNECNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLEPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPG K

Optionally, the Fc domain has one or more mutations at residues such asAsp-265, lysine 322, and Asn-434. In certain cases, the mutant Fc domainhaving one or more of these mutations (e.g., Asp-265 mutation) hasreduced ability of binding to the Fey receptor relative to a wildtype Fcdomain. In other cases, the mutant Fc domain having one or more of thesemutations (e.g., Asn-434 mutation) has increased ability of binding tothe MHC class I-related Fc-receptor (FcRN) relative to a wildtype Fcdomain. Fc domains from IgG2, IgG3 and IgG4 may also be used.

It is understood that different elements of the fusion proteins may bearranged in any manner that is consistent with the desiredfunctionality. For example, an ActRIIb polypeptide may be placedC-terminal to a heterologous domain, or, alternatively, a heterologousdomain may be placed C-terminal to an ActRIIb polypeptide. The ActRIIbpolypeptide domain and the heterologous domain need not be adjacent in afusion protein, and additional domains or amino acid sequences may beincluded C- or N-terminal to either domain or between the domains.

In certain embodiments, the ActRIIb polypeptides of the presentinvention contain one or more modifications that are capable ofstabilizing the ActRIIb polypeptides. For example, such modificationsenhance the in vitro half life of the ActRIIb polypeptides, enhancecirculatory half life of the ActRIIb polypeptides or reducingproteolytic degradation of the ActRIIb polypeptides. Such stabilizingmodifications include, but are not limited to, fusion proteins(including, for example, fusion proteins comprising an ActRIIbpolypeptide and a stabilizer domain), modifications of a glycosylationsite (including, for example, addition of a glycosylation site to anActRIIb polypeptide), and modifications of carbohydrate moiety(including, for example, removal of carbohydrate moieties from anActRIIb polypeptide). As used herein, the term “stabilizer domain” notonly refers to a fusion domain (e.g., Fc) as in the case of fusionproteins, but also includes nonproteinaceous modifications such as acarbohydrate moiety, or nonproteinaceous moiety, such as polyethyleneglycol.

In certain embodiments, the present invention makes available isolatedand/or purified forms of the ActRIIb polypeptides, which are isolatedfrom, or otherwise substantially free of, other proteins. ActRIIbpolypeptides will generally be produced by expression from recombinantnucleic acids.

3. Nucleic Acids Encoding ActRIIb Polypeptides

In certain aspects, the invention provides isolated and/or recombinantnucleic acids encoding any of the ActRIIb polypeptides (e.g.,full-length and soluble ActRIIb polypeptides), including fragments,functional variants and fusion proteins disclosed herein. For example,SEQ ID NO: 4 encodes the naturally occurring human ActRIIb precursorpolypeptide, while SEQ ID NO: 5 encodes the processed extracellulardomain of ActRIIb. The subject nucleic acids may be single-stranded ordouble stranded. Such nucleic acids may be DNA or RNA molecules. Thesenucleic acids may be used, for example, in methods for making ActRIIbpolypeptides or as direct therapeutic agents (e.g., in a gene therapyapproach).

In certain aspects, the subject nucleic acids encoding ActRIIbpolypeptides are further understood to include nucleic acids that arevariants of SEQ ID NO: 4 or 5. Variant nucleotide sequences includesequences that differ by one or more nucleotide substitutions, additionsor deletions, such as allelic variants.

In certain embodiments, the invention provides isolated or recombinantnucleic acid sequences that are at least 80%, 85%, 90%, 95%, 97%, 98%,99% or 100% identical to SEQ ID NOs: 4, 5, or 10. One of ordinary skillin the art will appreciate that nucleic acid sequences complementary toSEQ ID NOs: 4, 5, or 10 and variants of SEQ ID NOs: 4, 5, or 10 are alsowithin the scope of this invention. In further embodiments, the nucleicacid sequences of the invention can be isolated, recombinant, and/orfused with a heterologous nucleotide sequence, or in a DNA library.

In other embodiments, nucleic acids of the invention also includenucleotide sequences, and the ActRIIb polypeptides encoded by suchnucleic acids that hybridize under highly stringent conditions to thenucleotide sequence designated in SEQ ID NOs: 4, 5, or 10, thecomplement sequence of SEQ ID NOs: 4, 5, or 10, or fragments of any ofthe foregoing. As discussed above, one of ordinary skill in the art willunderstand readily that appropriate stringency conditions which promoteDNA hybridization can be varied. One of ordinary skill in the art willunderstand readily that appropriate stringency conditions which promoteDNA hybridization can be varied. For example, one could perform thehybridization at 6.0×sodium chloride/sodium citrate (SSC) at about 45°C., followed by a wash of 2.0×SSC at 50° C. For example, the saltconcentration in the wash step can be selected from a low stringency ofabout 2.0×SSC at 50° C. to a high stringency of about 0.2×SSC at 50° C.In addition, the temperature in the wash step can be increased from lowstringency conditions at room temperature, about 22° C., to highstringency conditions at about 65° C. Both temperature and salt may bevaried, or temperature or salt concentration may be held constant whilethe other variable is changed. In one embodiment, the invention providesnucleic acids which hybridize under low stringency conditions of 6×SSCat room temperature followed by a wash at 2×SSC at room temperature.

Isolated nucleic acids which differ from the nucleic acids as set forthin SEQ ID NOs: 4, 5, or 10 due to degeneracy in the genetic code arealso within the scope of the invention. For example, a number of aminoacids are designated by more than one triplet. Codons that specify thesame amino acid, or synonyms (for example, CAU and CAC are synonyms forhistidine) may result in “silent” mutations which do not affect theamino acid sequence of the protein. However, it is expected that DNAsequence polymorphisms that do lead to changes in the amino acidsequences of the subject proteins will exist among mammalian cells. Oneskilled in the art will appreciate that these variations in one or morenucleotides (up to about 3-5% of the nucleotides) of the nucleic acidsencoding a particular protein may exist among individuals of a givenspecies due to natural allelic variation. Any and all such nucleotidevariations and resulting amino acid polymorphisms are within the scopeof this invention.

In certain embodiments, the recombinant nucleic acids of the inventionmay be operably linked to one or more regulatory nucleotide sequences inan expression construct. Regulatory nucleotide sequences will generallybe appropriate to the host cell used for expression. Numerous types ofappropriate expression vectors and suitable regulatory sequences areknown in the art for a variety of host cells. Typically, said one ormore regulatory nucleotide sequences may include, but are not limitedto, promoter sequences, leader or signal sequences, ribosomal bindingsites, transcriptional start and termination sequences, translationalstart and termination sequences, and enhancer or activator sequences.Constitutive or inducible promoters as known in the art are contemplatedby the invention. The promoters may be either naturally occurringpromoters, or hybrid promoters that combine elements of more than onepromoter. An expression construct may be present in a cell on anepisome, such as a plasmid, or the expression construct may be insertedin a chromosome. In a preferred embodiment, the expression vectorcontains a selectable marker gene to allow the selection of transformedhost cells. Selectable marker genes are well known in the art and willvary with the host cell used.

In certain aspects of the invention, the subject nucleic acid isprovided in an expression vector comprising a nucleotide sequenceencoding an ActRIIb polypeptide and operably linked to at least oneregulatory sequence. Regulatory sequences are art-recognized and areselected to direct expression of the ActRIIb polypeptide. Accordingly,the term regulatory sequence includes promoters, enhancers, and otherexpression control elements. Exemplary regulatory sequences aredescribed in Goeddel; Gene Expression Technology: Methods in Enzymology,Academic Press, San Diego, Calif. (1990). For instance, any of a widevariety of expression control sequences that control the expression of aDNA sequence when operatively linked to it may be used in these vectorsto express DNA sequences encoding an ActRIIb polypeptide. Such usefulexpression control sequences, include, for example, the early and latepromoters of SV40, tet promoter, adenovirus or cytomegalovirus immediateearly promoter, RSV promoters, the lac system, the trp system, the TACor TRC system, T7 promoter whose expression is directed by T7 RNApolymerase, the major operator and promoter regions of phage lambda, thecontrol regions for fd coat protein, the promoter for 3-phosphoglyceratekinase or other glycolytic enzymes, the promoters of acid phosphatase,e.g., Pho5, the promoters of the yeast α-mating factors, the polyhedronpromoter of the baculovirus system and other sequences known to controlthe expression of genes of prokaryotic or eukaryotic cells or theirviruses, and various combinations thereof. It should be understood thatthe design of the expression vector may depend on such factors as thechoice of the host cell to be transformed and/or the type of proteindesired to be expressed. Moreover, the vector's copy number, the abilityto control that copy number and the expression of any other proteinencoded by the vector, such as antibiotic markers, should also beconsidered.

A recombinant nucleic acid of the invention can be produced by ligatingthe cloned gene, or a portion thereof, into a vector suitable forexpression in either prokaryotic cells, eukaryotic cells (yeast, avian,insect or mammalian), or both. Expression vehicles for production of arecombinant ActRIIb polypeptide include plasmids and other vectors. Forinstance, suitable vectors include plasmids of the types: pBR322-derivedplasmids, pEMBL-derived plasmids, pEX-derived plasmids, pBTac-derivedplasmids and pUC-derived plasmids for expression in prokaryotic cells,such as E. coli.

Some mammalian expression vectors contain both prokaryotic sequences tofacilitate the propagation of the vector in bacteria, and one or moreeukaryotic transcription units that are expressed in eukaryotic cells.The pcDNAI/amp, pcDNAI/neo, pRc/CMV, pSV2gpt, pSV2neo, pSV2-dhfr, pTk2,pRSVneo, pMSG, pSVT7, pko-neo and pHyg derived vectors are examples ofmammalian expression vectors suitable for transfection of eukaryoticcells. Some of these vectors are modified with sequences from bacterialplasmids, such as pBR322, to facilitate replication and drug resistanceselection in both prokaryotic and eukaryotic cells. Alternatively,derivatives of viruses such as the bovine papilloma virus (BPV-1), orEpstein-Barr virus (pHEBo, pREP-derived and p205) can be used fortransient expression of proteins in eukaryotic cells. Examples of otherviral (including retroviral) expression systems can be found below inthe description of gene therapy delivery systems. The various methodsemployed in the preparation of the plasmids and in transformation ofhost organisms are well known in the art. For other suitable expressionsystems for both prokaryotic and eukaryotic cells, as well as generalrecombinant procedures, see Molecular Cloning A Laboratory Manual, 3rdEd., ed. by Sambrook, Fritsch and Maniatis (Cold Spring HarborLaboratory Press, 2001). In some instances, it may be desirable toexpress the recombinant polypeptides by the use of a baculovirusexpression system. Examples of such baculovirus expression systemsinclude pVL-derived vectors (such as pVL1392, pVL1393 and pVL941),pAcUW-derived vectors (such as pAcUW1), and pBlueBac-derived vectors(such as the ß-gal containing pBlueBac III).

In a preferred embodiment, a vector will be designed for production ofthe subject ActRIIb polypeptides in CHO cells, such as a Pcmv-Scriptvector (Stratagene, La Jolla, Calif.), pcDNA4 vectors (Invitrogen,Carlsbad, Calif.) and pCI-neo vectors (Promega, Madison, Wis.). As willbe apparent, the subject gene constructs can be used to cause expressionof the subject ActRIIb polypeptides in cells propagated in culture,e.g., to produce proteins, including fusion proteins or variantproteins, for purification.

This disclosure also pertains to a host cell transfected with arecombinant gene including a coding sequence (e.g., SEQ ID NO: 4, 5, or10) for one or more of the subject ActRIIb polypeptides. The host cellmay be any prokaryotic or eukaryotic cell. For example, an ActRIIbpolypeptide of the invention may be expressed in bacterial cells such asE. coli, insect cells (e.g., using a baculovirus expression system),yeast, or mammalian cells. Other suitable host cells are known to thoseskilled in the art.

Accordingly, the present invention further pertains to methods ofproducing the subject ActRIIb polypeptides. For example, a host celltransfected with an expression vector encoding an ActRIIb polypeptidecan be cultured under appropriate conditions to allow expression of theActRIIb polypeptide to occur. The ActRIIb polypeptide may be secretedand isolated from a mixture of cells and medium containing the ActRIIbpolypeptide. Alternatively, the ActRIIb polypeptide may be retainedcytoplasmically or in a membrane fraction and the cells harvested, lysedand the protein isolated. A cell culture includes host cells, media andother byproducts. Suitable media for cell culture are well known in theart. The subject ActRIIb polypeptides can be isolated from cell culturemedium, host cells, or both, using techniques known in the art forpurifying proteins, including ion-exchange chromatography, gelfiltration chromatography, ultrafiltration, electrophoresis,immunoaffinity purification with antibodies specific for particularepitopes of the ActRIIb polypeptides and affinity purification with anagent that binds to a domain fused to the ActRIIb polypeptide (e.g., aprotein A column may be used to purify an ActRIIb-Fc fusion). In apreferred embodiment, the ActRIIb polypeptide is a fusion proteincontaining a domain which facilitates its purification. In a preferredembodiment, purification is achieved by a series of columnchromatography steps, including, for example, three or more of thefollowing, in any order: protein A chromatography, Q sepharosechromatography, phenylsepharose chromatography, size exclusionchromatography, and cation exchange chromatography. The purificationcould be completed with viral filtration and buffer exchange.

In another embodiment, a fusion gene coding for a purification leadersequence, such as a poly-(His)/enterokinase cleavage site sequence atthe N-terminus of the desired portion of the recombinant ActRIIbpolypeptide, can allow purification of the expressed fusion protein byaffinity chromatography using a Ni²⁺ metal resin. The purificationleader sequence can then be subsequently removed by treatment withenterokinase to provide the purified ActRIIb polypeptide (e.g., seeHochuli et al., (1987) J. Chromatography 411:177; and Janknecht et al.,PNAS USA 88:8972).

Techniques for making fusion genes are well known. Essentially, thejoining of various DNA fragments coding for different polypeptidesequences is performed in accordance with conventional techniques,employing blunt-ended or stagger-ended termini for ligation, restrictionenzyme digestion to provide for appropriate termini, filling-in ofcohesive ends as appropriate, alkaline phosphatase treatment to avoidundesirable joining, and enzymatic ligation. In another embodiment, thefusion gene can be synthesized by conventional techniques includingautomated DNA synthesizers. Alternatively, PCR amplification of genefragments can be carried out using anchor primers which give rise tocomplementary overhangs between two consecutive gene fragments which cansubsequently be annealed to generate a chimeric gene sequence (see, forexample, Current Protocols in Molecular Biology, eds. Ausubel et al.,John Wiley & Sons: 1992).

4. Alternative ActRIIb Antagonists

As demonstrated herein, an ActRIIb polypeptide is effective to increasereticulocyte levels in vivo, an effect which, over a longer time periodleads to increased hematocrit levels in certain species, and is likelyto do so in humans. Thus, in some embodiments, ActRIIb antagonists ofthe disclosure may be used increase red blood cell levels in vivo.Although soluble ActRIIb polypeptides, and particularly ActRIIb-Fc, arepreferred antagonists, and although such antagonists may affect redblood cell levels through a mechanism other than activin antagonism(e.g., activin inhibition may be an indicator of the tendency of anagent to inhibit the activities of a spectrum of molecules, including,perhaps, other members of the TGF-beta superfamily, and such collectiveinhibition may lead to the desired effect on hematopoiesis), other typesof ActRIIb antagonists are expected to be useful, including anti-ActRIIbantibodies, antisense, RNAi or ribozyme nucleic acids that inhibit theproduction of ActRIIb, and other inhibitors of ActRIIb, particularlythose that disrupt ActRIIb binding.

An antibody that is specifically reactive with an ActRIIb polypeptide(e.g., a soluble ActRIIbpolypeptide) and which either bindscompetitively to ligand with the ActRIIb polypeptide or otherwiseinhibits ActRIIb-mediated signaling may be used as an antagonist ofActRIIb polypeptide activities.

By using immunogens derived from an ActRIIb polypeptide,anti-protein/anti-peptide antisera or monoclonal antibodies can be madeby standard protocols (see, for example, Antibodies: A Laboratory Manualed. by Harlow and Lane (Cold Spring Harbor Press: 1988)). A mammal, suchas a mouse, a hamster or rabbit can be immunized with an immunogenicform of the ActRIIb polypeptide, an antigenic fragment which is capableof eliciting an antibody response, or a fusion protein. Techniques forconferring immunogenicity on a protein or peptide include conjugation tocarriers or other techniques well known in the art. An immunogenicportion of an ActRIIb polypeptide can be administered in the presence ofadjuvant. The progress of immunization can be monitored by detection ofantibody titers in plasma or serum. Standard ELISA or other immunoassayscan be used with the immunogen as antigen to assess the levels ofantibodies.

Following immunization of an animal with an antigenic preparation of anActRIIb polypeptide, antisera can be obtained and, if desired,polyclonal antibodies can be isolated from the serum. To producemonoclonal antibodies, antibody-producing cells (lymphocytes) can beharvested from an immunized animal and fused by standard somatic cellfusion procedures with immortalizing cells such as myeloma cells toyield hybridoma cells. Such techniques are well known in the art, andinclude, for example, the hybridoma technique (originally developed byKohler and Milstein, (1975) Nature, 256: 495-497), the human B cellhybridoma technique (Kozbar et al., (1983) Immunology Today, 4: 72), andthe EBV-hybridoma technique to produce human monoclonal antibodies (Coleet al., (1985) Monoclonal Antibodies and Cancer Therapy, Alan R. Liss,Inc. pp. 77-96). Hybridoma cells can be screened immunochemically forproduction of antibodies specifically reactive with an ActRIIbpolypeptide and monoclonal antibodies isolated from a culture comprisingsuch hybridoma cells.

The term “antibody” as used herein is intended to include wholeantibodies, e.g., of any isotype (IgG, IgA, IgM, IgE, etc), and includesfragments or domains of immunoglobulins which are reactive with aselected antigen. Antibodies can be fragmented using conventionaltechniques and the fragments screened for utility and/or interactionwith a specific epitope of interest. Thus, the term includes segments ofproteolytically-cleaved or recombinantly-prepared portions of anantibody molecule that are capable of selectively reacting with acertain protein. Non-limiting examples of such proteolytic and/orrecombinant fragments include Fab, F(ab′)2, Fab′, Fv, and single chainantibodies (scFv) containing a V[L] and/or V[H] domain joined by apeptide linker. The scFv's may be covalently or non-covalently linked toform antibodies having two or more binding sites. The term antibody alsoincludes polyclonal, monoclonal, or other purified preparations ofantibodies and recombinant antibodies. The term “recombinant antibody”,means an antibody, or antigen binding domain of an immunoglobulin,expressed from a nucleic acid that has been constructed using thetechniques of molecular biology, such as a humanized antibody or a fullyhuman antibody developed from a single chain antibody. Single domain andsingle chain antibodies are also included within the term “recombinantantibody”.

In certain embodiments, an antibody of the invention is a monoclonalantibody, and in certain embodiments, the invention makes availablemethods for generating novel antibodies. For example, a method forgenerating a monoclonal antibody that binds specifically to an ActRIIbpolypeptide may comprise administering to a mouse an amount of animmunogenic composition comprising the antigen polypeptide effective tostimulate a detectable immune response, obtaining antibody-producingcells (e.g., cells from the spleen) from the mouse and fusing theantibody-producing cells with myeloma cells to obtain antibody-producinghybridomas, and testing the antibody-producing hybridomas to identify ahybridoma that produces a monocolonal antibody that binds specificallyto the antigen. Once obtained, a hybridoma can be propagated in a cellculture, optionally in culture conditions where the hybridoma-derivedcells produce the monoclonal antibody that binds specifically to theantigen. The monoclonal antibody may be purified from the cell culture.

The adjective “specifically reactive with” as used in reference to anantibody is intended to mean, as is generally understood in the art,that the antibody is sufficiently selective between the antigen ofinterest (e.g., an ActRIIb polypeptide) and other antigens that are notof interest that the antibody is useful for, at minimum, detecting thepresence of the antigen of interest in a particular type of biologicalsample. In certain methods employing the antibody, such as therapeuticapplications, a higher degree of specificity in binding may bedesirable. Monoclonal antibodies generally have a greater tendency (ascompared to polyclonal antibodies) to discriminate effectively betweenthe desired antigens and cross-reacting polypeptides. One characteristicthat influences the specificity of an antibody:antigen interaction isthe affinity of the antibody for the antigen. Although the desiredspecificity may be reached with a range of different affinities,generally preferred antibodies will have an affinity (a dissociationconstant) of about 10⁻⁶, 10⁻⁷, 10⁻⁸, 10⁻⁹M or less.

In addition, the techniques used to screen antibodies in order toidentify a desirable antibody may influence the properties of theantibody obtained. For example, if an antibody is to be used for bindingan antigen in solution, it may be desirable to test solution binding. Avariety of different techniques are available for testing interactionbetween antibodies and antigens to identify particularly desirableantibodies. Such techniques include ELISAs, surface plasmon resonancebinding assays (e.g., the Biacore™ binding assay, Biacore AB, Uppsala,Sweden), sandwich assays (e.g., the paramagnetic bead system of IGENInternational, Inc., Gaithersburg, Md.), western blots,immunoprecipitation assays, and immunohistochemistry.

Examples of categories of nucleic acid compounds that are ActRIIbantagonists include antisense nucleic acids, RNAi constructs andcatalytic nucleic acid constructs. A nucleic acid compound may be singleor double stranded. A double stranded compound may also include regionsof overhang or non-complementarity, where one or the other of thestrands is single stranded. A single stranded compound may includeregions of self-complementarity, meaning that the compound forms aso-called “hairpin” or “stem-loop” structure, with a region of doublehelical structure. A nucleic acid compound may comprise a nucleotidesequence that is complementary to a region consisting of no more than1000, no more than 500, no more than 250, no more than 100, or no morethan 50, 35, 25, 22, 20, 18 or 15 nucleotides of the full-length ActRIIbnucleic acid sequence. The region of complementarity will preferably beat least 8 nucleotides, and optionally about 18 to 35 nucleotides. Aregion of complementarity may fall within an intron, a coding sequenceor a noncoding sequence of the target transcript, such as the codingsequence portion. Generally, a nucleic acid compound will have a lengthof about 8 to about 500 nucleotides or base pairs in length, andoptionally the length will be about 14 to about 50 nucleotides. Anucleic acid may be a DNA (particularly for use as an antisense), RNA orRNA:DNA hybrid. Any one strand may include a mixture of DNA and RNA, aswell as modified forms that cannot readily be classified as either DNAor RNA. Likewise, a double stranded compound may be DNA:DNA, DNA:RNA orRNA:RNA, and any one strand may also include a mixture of DNA and RNA,as well as modified forms that cannot readily be classified as eitherDNA or RNA. A nucleic acid compound may include any of a variety ofmodifications, including one or modifications to the backbone (thesugar-phosphate portion in a natural nucleic acid, includinginternucleotide linkages) or the base portion (the purine or pyrimidineportion of a natural nucleic acid). An antisense nucleic acid compoundwill preferably have a length of about 15 to about 30 nucleotides andwill often contain one or more modifications to improve characteristicssuch as stability in the serum, in a cell or in a place where thecompound is likely to be delivered, such as the stomach in the case oforally delivered compounds and the lung for inhaled compounds. In thecase of an RNAi construct, the strand complementary to the targettranscript will generally be RNA or modifications thereof. The otherstrand may be RNA, DNA or any other variation. The duplex portion ofdouble stranded or single stranded “hairpin” RNAi construct willgenerally have a length of 18 to 40 nucleotides in length and optionallyabout 21 to 23 nucleotides in length, so long as it serves as a Dicersubstrate. Catalytic or enzymatic nucleic acids may be ribozymes or DNAenzymes and may also contain modified forms. Nucleic acid compounds mayinhibit expression of the target by about 50%, 75%, 90% or more whencontacted with cells under physiological conditions and at aconcentration where a nonsense or sense control has little or no effect.Preferred concentrations for testing the effect of nucleic acidcompounds are 1, 5 and 10 micromolar. Nucleic acid compounds may also betested for effects on, for example, red blood cell levels.

In certain embodiments, alternative antagonists with properties that aresimilar to ActRIIb antagonists may be used. An antagonist may be afollistatin polypeptide that antagonizes activin bioactivity and/orbinds to activin and/or myostatin. The term “follistatin polypeptide”includes polypeptides comprising any naturally occurring polypeptide offollistatin as well as any variants thereof (including mutants,fragments, fusions, and peptidomimetic forms) that retain a usefulactivity, and further includes any functional monomer or multimer offollistatin. Variants of follistatin polypeptides that retain activinbinding properties can be identified based on previous studies involvingfollistatin and activin interactions. For example, WO2008/030367discloses specific follistatin domains (“FSDs”) that are shown to beimportant for activin binding. As shown below in SEQ ID NOs: 18-20, theN-terminus follistatin domain (“FSND” SEQ ID NO: 18), FSD2 (SEQ ID NO:19), and to a lesser extent FSD1 (SEQ ID NO: 20) represent exemplarydomains within follistatin important for activin binding. In addition,methods for making and testing libraries of polypeptides are describedabove in the context of ActRIIb polypeptides and such methods alsopertain to making and testing variants of follistatin. Additionally,forms of follistatin that bind myostatin preferentially (with reducedactivin binding) are also known and may be used as antagonists hereinthat may exhibit properties similar to those of ActRIIb antagonists;such follistatin forms may be found in, for example, WO/2005/100563 andWO/2008/030367). Follistatin polypeptides include polypeptides derivedfrom the sequence of any known follistatin having a sequence at leastabout 80% identical to the sequence of a follistatin polypeptide, andoptionally at least 85%, 90%, 95%, 97%, 99% or greater identity.Examples of follistatin polypeptides include the mature follistatinpolypeptide or shorter isoforms or other variants of the humanfollistatin precursor polypeptide (SEQ ID NO: 16) as described, forexample, in WO2005/025601.

The human follistatin precursor polypeptide isoform FST344 is asfollows:

MVRARHQPGGLCLLLLLLCQFMEDRSAQAGNCWLRQAKNGRCQVLYKTELSKEECCSTGRLSTSWTEEDVNDNTLFKWMIFNGGAPNCIPCKETCENVDCGPGKKCRMNKKNKPRCVCAPDCSNITWKGPVCGLDGKTYRNECALLKARCKEQPELEVQYQGRCKKTCRDVFCPGSSTCVVDQTNNAYCVTCNRICPEPASSEQYLCGNDGVTYSSACHLRKATCLLGRSIGLAYEGKCIKAKSCEDIQCTGGKKCLWDFKVGRGRCSLCDELCPDSKSDEPVCASDNATYASECAMKEAACSSGVLLEVKHGSCNSISEDTEEEEEDEDQDYSFPISSILEW(SEQ ID NO: 16; NP_037541.1 FOLLISTATIN ISOFORM FST344)The signal peptide is single underlined; the last 27 residues in boldrepresent additional amino acids as compared to a shorter follistatinisoform FST317 (NP_006341) below.

The human follistatin precursor polypeptide isoform FST317 is asfollows:

(SEQ ID NO: 17) MVRARHQPGGLCLLLLLLCQFMEDRSAQAGNCWLRQAKNGRCQVLYKTELSKEECCSTGRLSTSWTEEDVNDNTLFKWMIFNGGAPNCIPCKETCENVDCGPGKKCRMNKKNKPRCVCAPDCSNITWKGPVCGLDGKTYRNECALLKARCKEQPELEVQYQGRCKKTCRDVFCPGSSTCVVDQTNNAYCVTCNRICPEPASSEQYLCGNDGVTYSSACHLRKATCLLGRSIGLAYEGKCIKAKSCEDIQCTGGKKCLWDFKVGRGRCSLCDELCPDSKSDEPVCASDNATYASECAMKEAACSSGVLLEVKHSGSCNThe signal peptide is single underlined.

N-terminus follistatin domain (FSND) sequence is as follows:

(SEQ ID NO: 18; FSND) GNCWLRQAKNGRCQVLYKTELSKEECCSTGRLSTSWTEEDVNDNTLFKWMIFNGGAPNCIPCK

The FSD1 and FSD2 sequences are as follows:

(SEQ ID NO: 19; FSD1) ETCENVDCGPGKKCRMNKKNKPRCV (SEQ ID NO: 20; FSD2)KTCRDVFCPGSSTCVVDQTNNAYCVT

In other embodiments, an antagonist similar to an ActRIIb antagonist maybe a follistatin-like related gene (FLRG) that antagonizes activinbioactivity and/or binds to activin. The term “FLRG polypeptide”includes polypeptides comprising any naturally occurring polypeptide ofFLRG as well as any variants thereof (including mutants, fragments,fusions, and peptidomimetic forms) that retain a useful activity.Variants of FLRG polypeptides that retain activin or myostatin bindingproperties can be identified using routine methods to assay FLRG andactivin or myostatin interactions. See, for example, U.S. Pat. No.6,537,966. In addition, methods for making and testing libraries ofpolypeptides are described above in the context of ActRIIb polypeptidesand such methods also pertain to making and testing variants of FLRG.FLRG polypeptides include polypeptides derived from the sequence of anyknown FLRG having a sequence at least about 80% identical to thesequence of an FLRG polypeptide, and optionally at least 85%, 90%, 95%,97%, 99% or greater identity.

The human FLRG precursor polypeptide is as follows:

(SEQ ID NO: 21; NP_005851)MRPGAPGPLWPLPWGALAWAVGFVSSMGSGNPAPGGVCWLQQGQEATCSLVLQTDVTRAECCASGNIDTAWSNLTHPGNKINLLGFLGLVHCLPCKDSCDGVECGPGKACRMLGGRPRCECAPDCSGLPARLQVCGSDGATYRDECELRAARCRGHPDLSVMYRGRCRKSCEHVVCPRPQSCVVDQTGSAHCVVCRAAPCVPSSPGQELCGNNNVTYISSCHMRQATCFLGRSIGVRHAGSCAGT PEEPPGGESAEEEENFVThe signal peptide is single underlined.

In certain embodiments, functional variants or modified forms of thefollistatin polypeptides and FLRG polypeptides include fusion proteinhaving at least a portion of the follistatin polypeptides or FLRGpolypeptides and one or more fusion domains, such as, for example,domains that facilitate isolation, detection, stabilization ormultimerization of the polypeptide. Suitable fusion domains arediscussed in detail above with reference to the ActRIIb polypeptides. Inone embodiment, an antagonist is a fusion protein comprising a ligandbinding (e.g. activin binding) portion of a follistaton polypeptidefused to an Fc domain. In another embodiment, an antagonist is a fusionprotein comprising a ligand binding (e.g. activin binding) portion of anFLRG polypeptide fused to an Fc domain. Follistatin and FLRG have beenshown in the literature, and by the applicants with respect to FLRG, tohave affinities for Activin A in the picomolar range, indicating thatthese agents will inhibit activin A signaling to a similar degree asActRIIb-Fc.

5. Exemplary Therapeutic Methods

In certain embodiments, the present invention provides methods formanaging a patient that has been treated with, or is a candidate to betreated with, an ActRIIb antagonist or other antagonist described hereinby measuring one or more hematologic parameters in the patient. Thehematologic parameters may be used to evaluate appropriate dosing for apatient who is a candidate to be treated with an ActRIIb anatagonist orother antagonist described herein, to monitor the hematologic parametersduring treatment with an ActRIIb antagonist, to evaluate whether toadjust the dosage during treatment with an ActRIIb antagonist, and/or toevaluate an appropriate maintenance dose of an ActRIIb antagonist. Ifone or more of the hematologic parameters are outside the normal level,dosing with the ActRIIb antagonist may be reduced, delayed orterminated.

Hematologic parameters that may be measured in accordance with themethods provided herein include, for example, red blood cell levels,blood pressure, iron stores, and other agents found in bodily fluidsthat correlate with increased red blood cell levels, using artrecognized methods. Such parameters may be determined using a bloodsample from a patient. Increases in red blood cell levels, hemoglobinlevels, and/or hematocrit levels may cause increases in blood pressure.

Red blood cell levels may be determined, for example, by determining ared blood cell count, by measuring hemoglobin levels or by measuringhematocrit levels. A red blood cell count may be determined using acommercially available Coulter Counter. The normal range for a red bloodcell count is between 4.2-5.9 million cells/cm, although individualvariations should be taken into account. Hemoglobin levels may bedetermined by lysing the red blood cells, converting the hemoglobin intocyanomethemoglobin and measuring the amount of hemoglobin with acolorimeter. The normal ranges for hemoglobin are 14-18 gm/dl for adultmales and 12-16 gm-dl for adult females, although individual variationsshould be taken into account. Hematocrit (Hct) or packed cell volume(PCV) refers to the ratio of the volume of red blood cells to the volumeof whole blood. Hematocrit may be determined, for example, bycentrifugation of a blood sample followed by analysis of the layersproduced. Normal ranges for hematocrit are approximately 41-51% for menand 35-45% for women, although individual variations should be takeninto account.

Blood pressure, including systolic blood pressure, diastolic bloodpressure, or mean arterial blood pressure, may be determined using artrecognized methods. Blood pressure is most commonly measured using asphygmomanometer. Typical values for a resting, healthy adult human areapproximately 120 mmHg systolic and 80 mmHg diastolic, althoughindividual variations should be taken into account. Individualssuffering from hypertension typically have a blood pressure ≥140 mmHgsystolic and ≥90 diastolic blood pressure. Individuals having a levelabove normal but less than 140/90 mmHg are generally referred to asprehypertensive. Additional methods for measuring blood pressure may befound in Pickering et al., Hypertension 45: 142-161 (2005).

Iron stores may be measured using a variety of art recognized techniquesincluding, for example, by determining levels of one or more of thefollowing: serum ferritin (SF), transferrin saturation (TSAT), totaliron binding capacity, hemoglobin concentration, zinc protoporphyrin,mean cell volume (MCV), or transferrin receptor in serum. Serum ferritinlevels may be determined, for example, using an immunoassay such as anenzyme-linked immunosorbent assay (ELISA) or immunoturbidometry. Innormal patients, serum ferritin levels range from 13 to 220 ng/mL,although individual variations should be taken into account. Transferrinsaturation levels represent the proportion of transferrin bound to ironand may be determined by dividing serum iron by total iron bidingcapacity (TIBC). In normal patients, transferrin saturation levels rangefrom 20% to 40%, although individual variations should be taken intoaccount. Serum iron may be determiend using colorimetry and is expressedas ug/dl or umol/l. Total iron binding capacity reflects the totalcapacity of circulating transferrin bound to iron and may be determinedusing a colorimetric assay to determine the amount of iron that can bebound to unsaturated transferrin in vitro. The normal range of totaliron binding capacity is about 250-450 ug/dl, although individualvariations should be taken into account. Additional information aboutmeasuring iron stores may be found in the World Health Organizationreport entitled Assessing the Iron Status of Populations dated April2004 and in Yamanishi et al., Clinical Chemistry 48: 1565-1570 (2002).

In one embodiment, if one or more hematologic parameters are outside thenormal range, or on the high side of normal, in a patient who is acandidate to be treated with an ActRIIb antagonist then onset ofadministration of the ActRIIb antagonist may be delayed until thehematologic parameters have returned to a normal or acceptable leveleither naturally or via therapeutic intervention. For example, if acandidate patient is hypertensive or prehypertensive, then the patientmay be treated with a blood pressure lowering agent in order to reducethe patient's blood pressure. Any blood pressure lowering agentappropriate for the individual patient's condition may be usedincluding, for example, diuretics, adrenergic inhibitors (includingalpha blockers and beta blockers), vasodilators, calcium channelblockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensinII receptor blockers. Blood pressure may alternatively be treated usinga diet and exercise regimen. Similarly, if a candidate patient has ironstores that are lower than normal, or on the low side of normal, thenthe patient may be treated with an appropriate regimen of diet and/oriron supplements until the patient's iron stores have returned to anormal or acceptable level. For patients having higher than normal redblood cell levels and/or hemoglobin levels, then administration of theActRIIb antagonist may be delayed until the levels have returned to anormal or acceptable level.

In certain embodiments, if one or more hematologic parameters areoutside the normal range, or on the high side of normal, in a patientwho is a candidate to be treated with an ActRIIb antagonist then theonset of administration may be not be delayed. However, the dosageamount or frequency of dosing of the ActRIIb antagonist may be set at anamount that would reduce the risk of an unacceptable increase in thehematologic parameters arising upon administration of the ActRIIbantagonist. Alternatively, a therapeutic regimen may be developed forthe patient that combines an ActRIIb antagonist with a therapeutic agentthat addresses the undesirable level of the hematologic parameter. Forexample, if the patient has elevated blood pressure, then a therapeuticregimen involving administration of an ActRIIb antagonist and a bloodpressure lowering agent may be designed. For a patient having lower thandesired iron stores, a therapeutic regimen of an ActRIIb antagonist andiron supplementation may be developed.

In one embodiment, baseline parameter(s) for one or more hematologicparameters may be established for a patient who is a candidate to betreated with an ActRIIb antagonist and an appropriate dosing regimenestablish for that patient based on the baseline value(s).Alternatively, established baseline parameters based on a patient'smedical history could be used to inform an appropriate ActRIIbantagonist dosing regimen for a patient. For example, if a healthypatient has an established baseline blood pressure reading that is abovethe defined normal range it may not be necessary to bring the patient'sblood pressure into the range that is considered normal for the generalpopulation prior to treatment with the ActRIIb antagonist. A patient'sbaseline values for one or more hematologic parameters prior totreatment with an ActRIIb antagonist may also be used as the relevantcomparative values for monitoring any changes to the hematologicparameters during treatment with the ActRIIb antagonist.

In certain embodiments, one or more hematologic parameters are measuredin patients who are being treated with an ActRIIb antagonist. Thehematologic parameters may be used to monitor the patient duringtreatment and permit adjustment or termination of the dosing with theActRIIb antagonist or additional dosing with another therapeutic agent.For example, if administration of an ActRIIb antagonist results in anincrease in blood pressure, red blood cell level, or hemoglobin level,or a reduction in iron stores, then the dose of the ActRIIb antagonistsmay be reduced in amount or frequency in order to decrease the effectsof the ActRIIb antagonist on the one or more hematologic parameters. Ifadministration or an ActRIIb antagonist results in a change in one ormore hematologic parameters that is adverse to the patient, then thedosing of the ActRIIb antagonist may be terminated either temporarily,until the hematologic parameter(s) return to an acceptable level, orpermanently. Similarly, if one or more hematologic parameters are notbrought within an acceptable range after reducing the dose or frequencyof administration of the ActRIIb antagonist then the dosing may beterminated. As an alternative, or in addition to, reducing orterminating the dosing with the ActRIIb antagonist, the patient may bedosed with an additional therapeutic agent that addresses theundesirable level in the hematologic parameter(s), such as, for example,a blood pressure lowering agent or an iron supplement. For example, if apatient being treated with an ActRIIb antagonist has elevated bloodpressure, then dosing with the ActRIIb antagonist may continue at thesame level and a blood pressure lowering agent is added to the treatmentregimen, dosing with the ActRIIb antagonist may be reduce (e.g., inamount and/or frequency) and a blood pressure lowering agent is added tothe treatment regimen, or dosing with the ActRIIb antagonist may beterminated and the patient may be treated with a blood pressure loweringagent.

In certain embodiments, if a patient being treated with an ActRIIbantagonist or a patient who is a candidate for treatment with an ActRIIbantagonist has one or more of the following: a hemoglobin level greaterthan 12 g/dl, a hemoglobin level greater than 15 g/dl, a blood pressure≥120/80 mmHg, a blood pressure ≥140/90 mmHg, a transferrin saturationlevel less than 20%, and/or a ferritin level less than 100 ng/ml, thendosing with the ActRIIb antagonist is reduced, delayed or terminated. Asan alternative, or in addition to, reducing, delaying or terminatingdosing with ActRIIb antagonist, a therapeutic agent that addresses theundesired level of one or more hematologic parameters (such as a bloodpressure lowering agent or an iron supplement) may be administered tothe patient.

In one embodiment, the present invention provides a method for dosing apatient with an ActRIIb antagonist by administering to the patient anActRIIb antagonist in an amount and at a frequency which reduces therisk of causing a rise in hemoglobin levels greater than 1 g/dl over atwo week period. The methods may comprise measuring one or morehematologic parameters either before beginning administration of theActRIIb antagonist and/or during administration of the ActRIIbantagonist. The initial dose of the ActRIIb antagonist may be set so asto reduce the risk of causing a rise in hemoglobin levels greater than 1g/dl over a two week period. In addition, the dose may be adjusted overtime to in order to maintain a reduced risk of causing a rise inhemoglobin levels greater than 1 g/dl in two weeks.

In certain embodiments, the present invention provides a method foradministering an ActRIIb-Fc fusion protein to a patient by administeringthe ActRIIb fusion protein no more frequently than once per 10 days,once per 20 days, once per 30 days, once per 45 days, once per 60 days,once per 90 days, or once per 120 days, or 1-6 times per year, 2-6 timesper year, 1-5 times per year, 2-5 times per year, 1-4 times per year,2-4 times per year, 1-3 times per year, or 2-3 times per year.

In certain embodiments, the invention provides methods for determiningdosing and monitoring therapeutic progress with ActRIIb antagonisttreatment in patients in which the ActRIIb antagonist is beingadministered to increase red blood cell levels. The methods involvedetermining one or more hematologic parameters either prior to beginningdosing with the ActRIIb antagonist and/or during treatment with theActRIIb antagonist. For example, one or more hematologic parameters maybe determined in a patient who is a candidate for administration of anActRIIb antagonist for increasing blood cell levels to facilitatedetermination of dosage amount and frequency. One or more hematologicparameters may also be determined in a patient being treated with anActRIIb antagonist for purposes of increasing red blood cell levels inorder to monitor progress of the treatment, facilitate dosingadjustments, and to determine maintenance dosing levels, etc.

In accordance with the methods of the invention, one or more hematologicparameters may be measured at various time points and at varyingfrequencies as needed for an individual patient based on various factorssuch as a patient's baseline levels, responsiveness to treatment with anActRIIb antagonist, general health, age, sex, weight, etc. Measuring ofone or more hematologic parameters may be carried out before and/orduring treatment with an ActRIIb antagonist. If conducting multiplemeasurements of hematologic parameters at various time points, the sameset of hematologic parameter(s) need not be measured at each time point.Similarly, the same test for an individual parameter need not be used ateach time point. Appropriate hematologic parameters and tests for suchparameters may be chosen for an individual taking into account factorsspecific to the given individual. Testing of hematologic parameters mayoccur as frequently as needed for a given individual, such as, forexample, once per day, once per week, once per every two weeks, once permonth, once per each 2 month period, once per each 3 month period, onceper each 6 month period, or once per year. In addition, the frequency oftesting may vary over time. For example, upon initial dosing of anindividual it may be desirable to test for one or more hematologicparameters more frequently, e.g., once per day, once per week, once perevery two weeks, or once per month, and then decrease the frequency oftesting over time, e.g., after one month, two months, six months, 1year, two years, or longer, of treatment, the frequency of testing mayreduced to, for example, once per month, once per every two months, onceper every three months, once per every six months, or once per year.Similarly, it may be desirable to test more frequently when adjusting apatient's dose of an ActRIIb antagonist (e.g., either amount orfrequency of administration) and then decrease the frequency of testingover time, for example, once the patient's response to the ActRIIbantagonist has been established.

In various embodiments, patients being treated with an ActRIIbantagonist, or candidate patients for treatment with an ActRIIbantagonist, may be mammals such as rodents and primates, andparticularly human patients.

In certain embodiments, patients being treated with an ActRIIbantagonist, or candidate patients to be treated with an ActRIIbantagonist, are patients in need of bone and/or cartilage formation,prevention of bone loss, increased bone mineralization or prevention ofbone demineralization, such as patients with low bone density, decreasedbone strength, or bone damage due to breakage, loss or demineralization.In exemplary embodiments, the patients or candidate patients may bepatients suffering from, or at risk for developing, osteoporosis(including secondary osteoporosis), hyperparathyroidism, Cushing'sdisease, Paget's disease, thyrotoxicosis, chronic diarrheal state ormalabsorption, renal tubular acidosis, or anorexia nervosa. Osteoporosisresulting from drugs or another medical condition is known as secondaryosteoporosis. Medications that can cause secondary osteoporosis include,for example, corticosteroids, methotrexate (Rheumatrex, Immunex, FolexPFS), cyclosporine (Sandimmune, Neoral), luteinizing hormone-releasinghormone agonists (Lupron, Zoladex), and heparin (Calciparine,Liquaemin). Bone loss resulting from cancer therapy is widely recognizedand termed cancer therapy induced bone loss (CTIBL).

In certain embodiments, patients being treated with an ActRIIbantagonist, or candidate patients to be treated with an ActRIIbantagonist, are patients in need of muscle growth, such as patientssuffering from, or at risk of developing, a neuromuscular disorder ormusculogenerative disorder. For example, patients or candidate patientsmay be suffering from, or at risk for developing, Lou Gehrig's disease(ALS), cancer anorexia-cachexia syndrome, muscular dystrophy, muscleatrophy, congestive obstructive pulmonary disease (and muscle wastingassociated with COPD), muscle wasting syndrome, sarcopenia, or cachexia.Muscular dystrophy refers to a group of degenerative muscle diseasescharacterized by gradual weakening and deterioration of skeletal musclesand sometimes the heart and respiratory muscles. Exemplary musculardystrophies that can be treated with a regimen including the subjectActRIIB polypeptides include: Duchenne Muscular Dystrophy (DMD), BeckerMuscular Dystrophy (BMD), Emery-Dreifuss Muscular Dystrophy (EDMD),Limb-Girdle Muscular Dystrophy (LGMD), Facioscapulohumeral MuscularDystrophy (FSH or FSHD) (also known as Landouzy-Dejerine), MyotonicDystrophy (MMD) (also known as Steinert's Disease), OculopharyngealMuscular Dystrophy (OPMD), Distal Muscular Dystrophy (DD), CongenitalMuscular Dystrophy (CMD).

In certain embodiments, patients being treated with an ActRIIbantagonist, or candidate patients to be treated with an ActRIIbantagonist, are patients with undesirably low red blood cell orhemoglobin levels, such as patients having an anemia, and those that areat risk for developing undesirably low red blood cell or hemoglobinlevels, such as those patients that are about to undergo major surgeryor other procedures that may result in substantial blood loss, such ashaving blood drawn and stored for a later transfusion. Patients andcandidate patients may also include those patients in need of anincrease in red blood cells and/or hemoglobin levels that do not respondwell to Epo. When observing hemoglobin levels in humans, a level of lessthan normal for the appropriate age and gender category may beindicative of anemia, although individual variations are taken intoaccount. Potential causes of anemia include blood-loss, nutritionaldeficits, medication reaction, various problems with the bone marrow andmany diseases. More particularly, anemia has been associated with avariety of disorders that include, for example, chronic renal failure,myelodysplastic syndrome, rheumatoid arthritis, bone marrowtransplantation. Anemia may also be associated with the followingconditions: solid tumors (e.g. breast cancer, lung cancer, coloncancer); tumors of the lymphatic system (e.g. chronic lymphocyteleukemia, non-Hodgkins and Hodgkins lymphomas); tumors of thehematopoietic system (eg. leukemia, myelodysplastic syndrome, multiplemyeloma); radiation therapy; chemotherapy (e.g. platinum containingregimens); inflammatory and autoimmune diseases, including, but notlimited to, rheumatoid arthritis, other inflammatory arthritides,systemic lupus erythematosis (SLE), acute or chronic skin diseases (e.g.psoriasis), inflammatory bowel disease (e.g. Crohn's disease andulcerative colitis); acute or chronic renal disease or failure includingidiopathic or congenital conditions; acute or chronic liver disease;acute or chronic bleeding; situations where transfusion of red bloodcells is not possible due to patient allo- or auto-antibodies and/or forreligious reasons (e.g. some Jehovah's Witnesses); infections (e.g.malaria, osteomyelitis); hemoglobinopathies, including, for example,sickle cell disease, thalassemias; drug use or abuse, e.g. alcoholmisuse; pediatric patients with anemia from any cause to avoidtransfusion; and elderly patients or patients with underlyingcardiopulmonary disease with anemia who cannot receive transfusions dueto concerns about circulatory overload.

As used herein, a therapeutic that “prevents” a disorder or conditionrefers to a compound that, in a statistical sample, reduces theoccurrence of the disorder or condition in the treated sample relativeto an untreated control sample, or delays the onset or reduces theseverity of one or more symptoms of the disorder or condition relativeto the untreated control sample. The term “treating” as used hereinincludes prophylaxis of the named condition or amelioration orelimination of the condition once it has been established. In eithercase, prevention or treatment may be discerned in the diagnosis providedby a physician or other health care provider and the intended result ofadministration of the therapeutic agent.

6. Pharmaceutical Compositions

In certain embodiments, ActRIIb antagonists (e.g., ActRIIb polypeptides)of the present invention are formulated with a pharmaceuticallyacceptable carrier. For example, an ActRIIb polypeptide can beadministered alone or as a component of a pharmaceutical formulation(therapeutic composition). The subject compounds may be formulated foradministration in any convenient way for use in human or veterinarymedicine.

In certain embodiments, the therapeutic method of the invention includesadministering the composition systemically, or locally as an implant ordevice. When administered, the therapeutic composition for use in thisinvention is, of course, in a pyrogen-free, physiologically acceptableform. Therapeutically useful agents other than the ActRIIb antagonistswhich may also optionally be included in the composition as describedabove, may be administered simultaneously or sequentially with thesubject compounds (e.g., ActRIIb polypeptides) in the methods of theinvention.

Typically, ActRIIb antagonists will be administered parenterally.Pharmaceutical compositions suitable for parenteral administration maycomprise one or more ActRIIb-polypeptides in combination with one ormore pharmaceutically acceptable sterile isotonic aqueous or nonaqueoussolutions, dispersions, suspensions or emulsions, or sterile powderswhich may be reconstituted into sterile injectable solutions ordispersions just prior to use, which may contain antioxidants, buffers,bacteriostats, solutes which render the formulation isotonic with theblood of the intended recipient or suspending or thickening agents.Examples of suitable aqueous and nonaqueous carriers which may beemployed in the pharmaceutical compositions of the invention includewater, ethanol, polyols (such as glycerol, propylene glycol,polyethylene glycol, and the like), and suitable mixtures thereof,vegetable oils, such as olive oil, and injectable organic esters, suchas ethyl oleate. Proper fluidity can be maintained, for example, by theuse of coating materials, such as lecithin, by the maintenance of therequired particle size in the case of dispersions, and by the use ofsurfactants.

Further, the composition may be encapsulated or injected in a form fordelivery to a target tissue site (e.g., bone marrow). In certainembodiments, compositions of the present invention may include a matrixcapable of delivering one or more compounds (e.g., ActRIIb polypeptides)to a target tissue site (e.g., bone marrow), providing a structure forthe developing tissue and optimally capable of being resorbed into thebody. For example, the matrix may provide slow release of the ActRIIbpolypeptides. Such matrices may be formed of materials presently in usefor other implanted medical applications.

The choice of matrix material is based on biocompatibility,biodegradability, mechanical properties, cosmetic appearance andinterface properties. The particular application of the subjectcompositions will define the appropriate formulation. Potential matricesfor the compositions may be biodegradable and chemically defined calciumsulfate, tricalciumphosphate, hydroxyapatite, polylactic acid andpolyanhydrides. Other potential materials are biodegradable andbiologically well defined, such as bone or dermal collagen. Furthermatrices are comprised of pure proteins or extracellular matrixcomponents. Other potential matrices are non-biodegradable andchemically defined, such as sintered hydroxyapatite, bioglass,aluminates, or other ceramics. Matrices may be comprised of combinationsof any of the above mentioned types of material, such as polylactic acidand hydroxyapatite or collagen and tricalciumphosphate. The bioceramicsmay be altered in composition, such as in calcium-aluminate-phosphateand processing to alter pore size, particle size, particle shape, andbiodegradability.

In certain embodiments, methods of the invention can be administered fororally, e.g., in the form of capsules, cachets, pills, tablets, lozenges(using a flavored basis, usually sucrose and acacia or tragacanth),powders, granules, or as a solution or a suspension in an aqueous ornon-aqueous liquid, or as an oil-in-water or water-in-oil liquidemulsion, or as an elixir or syrup, or as pastilles (using an inertbase, such as gelatin and glycerin, or sucrose and acacia) and/or asmouth washes and the like, each containing a predetermined amount of anagent as an active ingredient. An agent may also be administered as abolus, electuary or paste.

In solid dosage forms for oral administration (capsules, tablets, pills,dragees, powders, granules, and the like), one or more therapeuticcompounds of the present invention may be mixed with one or morepharmaceutically acceptable carriers, such as sodium citrate ordicalcium phosphate, and/or any of the following: (1) fillers orextenders, such as starches, lactose, sucrose, glucose, mannitol, and/orsilicic acid; (2) binders, such as, for example, carboxymethylcellulose,alginates, gelatin, polyvinyl pyrrolidone, sucrose, and/or acacia; (3)humectants, such as glycerol; (4) disintegrating agents, such asagar-agar, calcium carbonate, potato or tapioca starch, alginic acid,certain silicates, and sodium carbonate; (5) solution retarding agents,such as paraffin; (6) absorption accelerators, such as quaternaryammonium compounds; (7) wetting agents, such as, for example, cetylalcohol and glycerol monostearate; (8) absorbents, such as kaolin andbentonite clay; (9) lubricants, such a talc, calcium stearate, magnesiumstearate, solid polyethylene glycols, sodium lauryl sulfate, andmixtures thereof; and (10) coloring agents. In the case of capsules,tablets and pills, the pharmaceutical compositions may also comprisebuffering agents. Solid compositions of a similar type may also beemployed as fillers in soft and hard-filled gelatin capsules using suchexcipients as lactose or milk sugars, as well as high molecular weightpolyethylene glycols and the like.

Liquid dosage forms for oral administration include pharmaceuticallyacceptable emulsions, microemulsions, solutions, suspensions, syrups,and elixirs. In addition to the active ingredient, the liquid dosageforms may contain inert diluents commonly used in the art, such as wateror other solvents, solubilizing agents and emulsifiers, such as ethylalcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzylalcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils(in particular, cottonseed, groundnut, corn, germ, olive, castor, andsesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycolsand fatty acid esters of sorbitan, and mixtures thereof. Besides inertdiluents, the oral compositions can also include adjuvants such aswetting agents, emulsifying and suspending agents, sweetening,flavoring, coloring, perfuming, and preservative agents.

Suspensions, in addition to the active compounds, may contain suspendingagents such as ethoxylated isostearyl alcohols, polyoxyethylenesorbitol, and sorbitan esters, microcrystalline cellulose, aluminummetahydroxide, bentonite, agar-agar and tragacanth, and mixturesthereof.

The compositions of the invention may also contain adjuvants, such aspreservatives, wetting agents, emulsifying agents and dispersing agents.Prevention of the action of microorganisms may be ensured by theinclusion of various antibacterial and antifungal agents, for example,paraben, chlorobutanol, phenol sorbic acid, and the like. It may also bedesirable to include isotonic agents, such as sugars, sodium chloride,and the like into the compositions. In addition, prolonged absorption ofthe injectable pharmaceutical form may be brought about by the inclusionof agents which delay absorption, such as aluminum monostearate andgelatin.

It is understood that the dosage regimen will be determined by theattending physician considering various factors which modify the actionof the subject of the invention (e.g., ActRIIb polypeptides). Thevarious factors include, but are not limited to, the patient's red bloodcell count, hemoglobin level or other diagnostic assessments, thedesired target red blood cell count, the patient's age, sex, and diet,the severity of any disease that may be contributing to a depressed redblood cell level, time of administration, and other clinical factors.The addition of other known growth factors to the final composition mayalso affect the dosage. Progress can be monitored by periodic assessmentof red blood cell and hemoglobin levels, as well as assessments ofreticulocyte levels and other indicators of the hematopoietic process.

In certain embodiments, effects on red blood cell levels in humans maybe obtained when ActRIIb-Fc is dosed at intervals and amounts sufficientto achieve serum concentrations of about 100 ng/ml or greater, for aperiod of at least about 20 to 30 days. Dosing to obtain serum levels of200 ng/ml, 500 ng/ml, 1000 ng/ml or greater for a period of at least 20to 30 days may also be used. Bone effects can be observed at serumlevels of about 200 ng/ml, with substantial effects beginning at about1000 ng/ml or higher, over a period of at least about 20 to 30 days.Thus, if it is desirable to achieve effects on red blood cells whilehaving little effect on bone, a dosing scheme may be designed to delivera serum concentration of between about 100 and 1000 ng/ml over a periodof about 20 to 30 days. Alternatively, if it is desirable to achieveeffects on bone, muscle, etc., while having little effect on, orreducing effects on red blood cell levels, a dosing scheme may bedesigned to deliver a dosing scheme of between about 100 and 1000 ng/mlwith a dosing frequency that occurs less than once every 60 days, onceevery 90 days, or once every 120 days. In humans, serum levels of 200ng/ml may be achieved with a single dose of 0.1 mg/kg or greater andserum levels of 1000 ng/ml may be achieved with a single dose of 0.3mg/kg or greater. The observed serum half-life of the molecule isbetween about 20 and 30 days, substantially longer than most Fc fusionproteins, and thus a sustained effective serum level may be achieved,for example, by dosing with about 0.05 to 0.5 mg/kg on a weekly orbiweekly basis, or higher doses may be used with longer intervalsbetween dosings. For example, doses of 0.1 to 1 mg/kg might be used on amonthly or bimonthly basis.

In certain embodiments, the present invention also provides gene therapyfor the in vivo production of ActRIIb polypeptides. Such therapy wouldachieve its therapeutic effect by introduction of the ActRIIbpolynucleotide sequences into cells or tissues having the disorders aslisted above. Delivery of ActRIIb polynucleotide sequences can beachieved using a recombinant expression vector such as a chimeric virusor a colloidal dispersion system. Preferred for therapeutic delivery ofActRIIb polynucleotide sequences is the use of targeted liposomes.

Various viral vectors which can be utilized for gene therapy as taughtherein include adenovirus, herpes virus, vaccinia, or an RNA virus suchas a retrovirus. The retroviral vector may be a derivative of a murineor avian retrovirus. Examples of retroviral vectors in which a singleforeign gene can be inserted include, but are not limited to: Moloneymurine leukemia virus (MoMuLV), Harvey murine sarcoma virus (HaMuSV),murine mammary tumor virus (MuMTV), and Rous Sarcoma Virus (RSV). Anumber of additional retroviral vectors can incorporate multiple genes.All of these vectors can transfer or incorporate a gene for a selectablemarker so that transduced cells can be identified and generated.Retroviral vectors can be made target-specific by attaching, forexample, a sugar, a glycolipid, or a protein. Preferred targeting isaccomplished by using an antibody. Those of skill in the art willrecognize that specific polynucleotide sequences can be inserted intothe retroviral genome or attached to a viral envelope to allow targetspecific delivery of the retroviral vector containing the ActRIIbpolynucleotide.

Alternatively, tissue culture cells can be directly transfected withplasmids encoding the retroviral structural genes gag, pol and env, byconventional calcium phosphate transfection. These cells are thentransfected with the vector plasmid containing the genes of interest.The resulting cells release the retroviral vector into the culturemedium.

Another targeted delivery system for ActRIIb polynucleotides is acolloidal dispersion system. Colloidal dispersion systems includemacromolecule complexes, nanocapsules, microspheres, beads, andlipid-based systems including oil-in-water emulsions, micelles, mixedmicelles, and liposomes. The preferred colloidal system of thisinvention is a liposome. Liposomes are artificial membrane vesicleswhich are useful as delivery vehicles in vitro and in vivo. RNA, DNA andintact virions can be encapsulated within the aqueous interior and bedelivered to cells in a biologically active form (see e.g., Fraley, etal., Trends Biochem. Sci., 6:77, 1981). Methods for efficient genetransfer using a liposome vehicle, are known in the art, see e.g.,Mannino, et al., Biotechniques, 6:682, 1988. The composition of theliposome is usually a combination of phospholipids, usually incombination with steroids, especially cholesterol. Other phospholipidsor other lipids may also be used. The physical characteristics ofliposomes depend on pH, ionic strength, and the presence of divalentcations.

Examples of lipids useful in liposome production include phosphatidylcompounds, such as phosphatidylglycerol, phosphatidylcholine,phosphatidylserine, phosphatidylethanolamine, sphingolipids,cerebrosides, and gangliosides. Illustrative phospholipids include eggphosphatidylcholine, dipalmitoylphosphatidylcholine, anddistearoylphosphatidylcholine. The targeting of liposomes is alsopossible based on, for example, organ-specificity, cell-specificity, andorganelle-specificity and is known in the art.

EXEMPLIFICATION

The invention now being generally described, it will be more readilyunderstood by reference to the following examples, which are includedmerely for purposes of illustration of certain embodiments andembodiments of the present invention, and are not intended to limit theinvention.

Example 1. Generation of ActRIIb-Fc Fusion Proteins

Applicants constructed a soluble ActRIIb fusion protein that has theextracellular domain of human ActRIIb fused to a human or mouse Fcdomain with a minimal linker (three glycine amino acids) in between. Theconstructs are referred to as ActRIIb-hFc and ActRIIb-mFc, respectively.

ActRIIb-hFc is shown below as purified from CHO cell lines (SEQ ID NO:8):

GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLEPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

The ActRIIb-hFc and ActRIIb-mFc proteins were expressed in CHO celllines. Three different leader sequences were considered:

(i) Honey bee mellitin (HBML): MKFLVNVALVFMVVYISYIYA (SEQ ID NO: 11);

(ii) Tissue Plasminogen Activator (TPA): MDAMKRGLCCVLLLCGAVFVSP (SEQ IDNO: 12); and

(iii) Native: MGAAAKLAFAVFLISCSSGA (SEQ ID NO: 13).

The selected form employs the TPA leader and has the followingunprocessed amino acid sequence (SEQ ID NO: 9):

MDAMKRGLCCVLLLCGAVFVSPGASGRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGTIELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEAGGPEVTYEPPPTAPTGGGTHTCPPCPAPELLGGPSVFLEPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

This polypeptide is encoded by the following nucleic acid sequence (SEQID NO: 10):

A TGGATGCAAT GAAGAGAGGG CTCTGCTGTG TGCTGCTGCT GTGTGGAGCA GTCTTCGTTTCGCCCGGCGC CTCTGGGCGT GGGGAGGCTG AGACACGGGA GTGCATCTAC TACAACGCCAACTGGGAGCT GGAGCGCACC AACCAGAGCG GCCTGGAGCG CTGCGAAGGC GAGCAGGACAAGCGGCTGCA CTGCTACGCC TCCTGGCGCA ACAGCTCTGG CACCATCGAG CTCGTGAAGAAGGGCTGCTG GCTAGATGAC TTCAACTGCT ACGATAGGCA GGAGTGTGTG GCCACTGAGGAGAACCCCCA GGTGTACTTC TGCTGCTGTG AAGGCAACTT CTGCAACGAG CGCTTCACTCATTTGCCAGA GGCTGGGGGC CCGGAAGTCA CGTACGAGCC ACCCCCGACA GCCCCCACCGGTGGTGGAAC TCACACATGC CCACCGTGCC CAGCACCTGA ACTCCTGGGG GGACCGTCAGTCTTCCTCTT CCCCCCAAAA CCCAAGGACA CCCTCATGAT CTCCCGGACC CCTGAGGTCACATGCGTGGT GGTGGACGTG AGCCACGAAG ACCCTGAGGT CAAGTTCAAC TGGTACGTGGACGGCGTGGA GGTGCATAAT GCCAAGACAA AGCCGCGGGA GGAGCAGTAC AACAGCACGTACCGTGTGGT CAGCGTCCTC ACCGTCCTGC ACCAGGACTG GCTGAATGGC AAGGAGTACAAGTGCAAGGT CTCCAACAAA GCCCTCCCAG TCCCCATCGA GAAAACCATC TCCAAAGCCAAAGGGCAGCC CCGAGAACCA CAGGTGTACA CCCTGCCCCC ATCCCGGGAG GAGATGACCAAGAACCAGGT CAGCCTGACC TGCCTGGTCA AAGGCTTCTA TCCCAGCGAC ATCGCCGTGGAGTGGGAGAG CAATGGGCAG CCGGAGAACA ACTACAAGAC CACGCCTCCC GTGCTGGACTCCGACGGCTC CTTCTTCCTC TATAGCAAGC TCACCGTGGA CAAGAGCAGG TGGCAGCAGGGGAACGTCTT CTCATGCTCC GTGATGCATG AGGCTCTGCA CAACCACTAC ACGCAGAAGAGCCTCTCCCT GTCTCCGGGT AAATGA

N-terminal sequencing of the CHO-cell produced material revealed a majorsequence of -GRGEAE (SEQ ID NO: 22). Notably, other constructs reportedin the literature begin with an -SGR . . . sequence.

Purification could be achieved by a series of column chromatographysteps, including, for example, three or more of the following, in anyorder: protein A chromatography, Q sepharose chromatography,phenylsepharose chromatography, size exclusion chromatography, andcation exchange chromatography. The purification could be completed withviral filtration and buffer exchange.

ActRIIb-Fc fusion proteins were also expressed in HEK293 cells and COScells. Although material from all cell lines and reasonable cultureconditions provided protein with muscle-building activity in vivo,variability in potency was observed perhaps relating to cell lineselection and/or culture conditions.

Applicants generated a series of mutations in the extracellular domainof ActRIIB and produced these mutant proteins as soluble fusion proteinsbetween extracellular ActRIIB and an Fc domain. The backgroundActRIIB-Fc fusion has the sequence of SEQ ID NO: 6. Various mutations,including N- and C-terminal truncations, were introduced into thebackground ActRIIB-Fc protein. Based on the data presented in Example 1,it is expected that these constructs, if expressed with a TPA leader,will lack the N-terminal serine. Mutations were generated in ActRIIBextracellular domain by PCR mutagenesis. After PCR, fragments werepurified through a Qiagen column, digested with SfoI and AgeI and gelpurified. These fragments were ligated into expression vector pAID4 (seeWO2006/012627) such that upon ligation it created fusion chimera withhuman IgG1. Upon transformation into E. coli DH5 alpha, colonies werepicked and DNAs were isolated. For murine constructs (mFc), a murineIgG2a was substituted for the human IgG1. All mutants were sequenceverified.

All of the mutants were produced in HEK293T cells by transienttransfection. In summary, in a 500 ml spinner, HEK293T cells were set upat 6×10⁵ cells/ml in Freestyle (Invitrogen) media in 250 ml volume andgrown overnight. Next day, these cells were treated with DNA:PEI (1:1)complex at 0.5 ug/ml final DNA concentration. After 4 hrs, 250 ml mediawas added and cells were grown for 7 days. Conditioned media washarvested by spinning down the cells and concentrated.

Mutants were purified using a variety of techniques, including, forexample, protein A column and eluted with low pH (3.0) glycine buffer.After neutralization, these were dialyzed against PBS.

Mutants were also produced in CHO cells by similar methodology.

Mutants were tested in binding assays and/or bioassays described.Characteristics of various ActRIIb variants are described inWO/2008/097541 and WO/2006/012627, incorporated by reference herein. Insome instances, assays were performed with conditioned medium ratherthan purified proteins. Additional variations of ActRIIb are describedin U.S. application Ser. No. 12/012,652.

Example 2. ActRIIb-hFc Stimulates Erythropoiesis in Non-Human Primates

ActRIIb-hFc (IgG1) was administered once a week for 1-month to male andfemale cynomolgus monkeys by subcutaneous injection. Forty-eightcynomolgus monkeys (24/sex) were assigned to one of four treatmentgroups (6 animals/sex/group) and were administered subcutaneousinjections of either vehicle or ActRIIb-hFc at 3, 10, or 30 mg/kg onceweekly for 4 weeks (total of 5 doses). Parameters evaluated includedgeneral clinical pathology (hematology, clinical chemistry, coagulation,and urinalysis). ActRIIb-hFc caused statistically significant elevatedmean absolute reticulocyte values by day 15 in treated animals. By day36, ActRIIb-hFc caused several hematological changes, including elevatedmean absolute reticulocyte and red blood cell distribution width valuesand lower mean corpuscular hemoglobin concentration. All treated groupsand both sexes were affected. These effects are consistent with apositive effect of ActRIIb-hFc on the release of immature reticulocytesfrom the bone marrow. This effect was reversed after drug was washed outof the treated animals (by study day 56). Accordingly, we conclude thatActRIIb-hFc stimulates erythropoiesis.

Example 3. ActRIIb-mFc Promotes Aspects of Erythropoiesis in Mice byStimulation of Splenic Erythropoietic Activities

In this study the effects of the in vivo administration of ActRIIb-mFcon the frequency of hematopoietic progenitors in bone marrow and spleenwas analyzed. One group of Black6 mice was injected with PBS as acontrol and a second group of mice administered two doses of ActRIIb-mFcat 10 mg/kg and both groups sacrificed after 8 days. Peripheral bloodwas used to perform complete blood counts and femurs and spleens wereused to perform in vitro clonogenic assays to assess the lymphoid,erythroid and myeloid progenitor cell content in each organ. In thebrief time frame of this study, no significant changes were seen in redblood cell, hemoglobin or white blood cell levels in treated mice. Inthe femurs there was no difference in the nucleated cell numbers orprogenitor content between the control and treated groups. In thespleens, the compound treated group experienced a statisticallysignificant increase in the mature erythroid progenitor (CFU-E) colonynumber per dish, frequency and total progenitor number per spleen. Inaddition, and increase was seen in the number of myeloid (CFU-GM),immature erythroid (BFU-E) and total progenitor number per spleen.

Except for the strain of mouse used, the detailed methodology in thisstudy was the same as that described above in Example 6. Mean values(+/−SD) for each group are shown in the tables below.

TABLE Hematologic Parameters White Blood Red Blood Treatment Cells CellsHemoglobin Hematocrit Group (×10⁹/L) (×10⁹/L) (g/L) (L/L) PBS 9.53 +/−1.44 10.5 +/− 1.1 160.9 +/− 13.3 0.552 +/− 0.057 (n = 8) ActRIIb-mFc9.77 +/− 1.19 10.8 +/− 0.3 162.1 +/− 4.1  0.567 +/− 0.019 (n = 8)

TABLE CFC From Femur and Spleen Total CFC per Total CFC per Total CFU-Eper Total CFU-E per Treatment Group Femur Spleen Femur Spleen PBS 88 +/−10 54 +/− 14 156 +/− 27 131 +/− 71  (n = 8) ActRIIb-mFc 85 +/− 9  79 +/−6* 164 +/− 23 436 +/− 86* (n = 8) *preliminary analysis indicates p <0.05

Treatment of mice with ActRIIb-mFc, in the brief time frame of thisstudy, did not result in significant increases in red blood cell orhemoglobin content. In the femurs there was no difference in thenucleated cell numbers or progenitor content between the control andtreated groups. In the spleens, the compound treated group experienced astatistically significant increase in the nucleated cell number beforered blood cell lysis and in the mature erythroid progenitor (CFU-E)colony number per dish, frequency and total progenitor number perspleen. In addition, an increase was seen in the number of myeloid(CFU-GM), immature erythroid (BFU-E) and total progenitor number perspleen. Accordingly, it is expected that over a longer time course,ActRIIb-mFc treatment may result in elevated red blood cell andhemoglobin content.

Example 4: Effects of ActRIIb-Fc on Various Species in Longer-TermStudies

ActRIIb-Fc has a statistically significant effect on hematologicparameters in rodents. In a 3-month multidose study of ActRIIb-hFc inrats, significant increases in hemoglobin concentration or RBC countwere observed, and reticulocyte concentrations increased in adose-dependent manner.

TABLE Hematologic parameters in 3-month study in Sprague-Dawley rats Sex(n) Males (10/group) Dose (mg/kg) Vehicle  3      10      60     RBC(×10⁶/μL)  8.6  9.9 *  10.2 *  9.1 * Hemoglobin (g/dL)  15.9  17.4 * 17.9 *  16.4   Reticulocytes (×10⁹/L) 176   250 *   272 *   446 *   Sex(n) Females (10/group) Dose (mg/kg) Vehicle  3      10      30     RBC(×10⁶/μL)  8.2  8.7    9.3 *  9.7 * Hemoglobin (g/dL)  15.7  16.2   16.5    17.5   Reticulocytes (×10⁹/L) 169   200     239     332 *   *Statistically significant vs. vehicle (P ≤ 0.05)

Interestingly, in a 3-month multidose study of ActRIIB-hFc in cynomolgusmonkeys there were no significant increases in hematocrit levels,hemoglobin levels, or RBC count, and reticulocyte concentrationsincreased modestly over the course of the study. In a Phase Ia trial ofActRIIB-hFC, there were increases in hematologic parameters at somedoses, with elevations typically observed at the highest dose levelswithin days of the first dose and at study completion. These dataindicate that ActRIIB-Fc fusion proteins can be used to increasehematologic parameters in humans.

Example 5: ActRIIb-mFc Increases Muscle Mass in Mice

As described in U.S. patent application Ser. No. 12/012,652, ActRIIb-mFcis effective to promote growth of muscle mass in a variety of mousemodels of human muscle disorders, including muscle dystrophy,amyotrophic lateral sclerosis and cancer cachexia. These findings areincorporated herein by reference, and as an example, one set of thisdata is presented here.

Applicants tested the ability of ActRIIB (R64 20-134)-mFc to attenuatemuscle loss in a mouse model of glucocorticoid-induced muscle wasting.

Mice were subcutaneously dosed daily for 13 days with either PBS ordexamethasone (2 mg/kg) to induce muscle wasting. Over the same 13 days,PBS- and dexamethosone-treated groups received vehicle or ActRIIB (R6420-134)-mFc (10 mg/kg; i.p.; twice/week) such that all combinations oftreatments were represented. Mice were NMR scanned at days 0 and 13 todetermine changes in lean tissue mass across the groups. NMR results areoutlined in Table 6, below.

TABLE 6 Lean tissue mass of vehicle- and murine ActRIIB (R6420-134)-Fc-treated mice Group Avg lean day 13-Avg lean day 0 (sc:iptreatment) (g) ± std dev PBS:PBS 0.83 ± 0.94   Dexameth:PBS 0.47 ±0.34^(a ) Dexameth:ActRIIB 2.56 ± 0.37^(a,b) PBS:ActRIIB 3.63 ±0.62^(a ) ^(a)Significant difference compared to PBS:PBS at p < 0.05^(b)Significant difference compared to Dexameth:PBS at p < 0.05

NMR scanning showed a significant 2.5% decrease in lean tissue mass inthe dexamethasone:PBS group compared to the PBS:PBS cohort. In contrast,the dexamethasone: ActRIIB (R64 20-134)-mFc group exhibited a 13.5%increase in lean tissue mass, a significant increase when compared toboth the PBS:PBS and the dexamethasone:PBS groups. Cachexia is anundesirable side effect for a variety of therapeutic treatments,including chronic glucocorticoid therapy. Therefore it could be ofclinical importance that treatment with a human ActRIM (R64 20-134)-mFcprotein can attenuate the muscle wasting associated with cachexia.

INCORPORATION BY REFERENCE

All publications and patents mentioned herein are hereby incorporated byreference in their entirety as if each individual publication or patentwas specifically and individually indicated to be incorporated byreference.

While specific embodiments of the subject matter have been discussed,the above specification is illustrative and not restrictive. Manyvariations will become apparent to those skilled in the art upon reviewof this specification and the claims below. The full scope of theinvention should be determined by reference to the claims, along withtheir full scope of equivalents, and the specification, along with suchvariations.

1. A method for managing a patient that has been treated with, or is acandidate to be treated with, a follistatin fusion protein, the methodcomprising monitoring in the patient one or more hematologic parametersthat correlate with increased red blood cell levels.
 2. The method ofclaim 1, wherein the hematologic parameters are one or more of thefollowing: red blood cell levels, blood pressure, or iron stores.
 3. Themethod of claim 1, the method further comprising administering to thepatient the follistatin fusion protein in an amount that is appropriateto the observed level of said hematologic parameter in the patient. 4.The method of claim 1, wherein, if the patient has blood pressureelevated above baseline or is hypertensive, dosing with the follistatinfusion protein is reduced, delayed or terminated.
 5. The method of claim1, wherein, if the patient has blood pressure elevated above baseline oris hypertensive, the patient is treated with a blood pressure loweringagent prior to administration of the follistatin fusion protein.
 6. Themethod of claim 1, wherein if the patient has uncontrolled hypertension,dosing with the follistatin fusion protein is reduced, delayed orterminated.
 7. The method of claim 1, wherein if the patient has a redblood cell level greater than the normal range for patients of similarage and sex, dosing with the follistatin fusion protein is reduced,delayed or terminated.
 8. The method of claim 1, wherein if the patienthas a hemoglobin level of greater than 15 g/dl, dosing with thefollistatin fusion protein is reduced, delayed or terminated.
 9. Themethod of claim 1, wherein if the patient has a hemoglobin level greaterthan 10, 11 or 12 g/dl, dosing with the activin-follistatin fusionprotein is reduced, delayed or terminated.
 10. The method of claim 1,wherein if the patient has iron stores that are lower than the normalrange for patients of similar age and sex, dosing with the follistatinfusion protein is reduced, delayed or terminated.
 11. The method ofclaim 1, wherein if the patient has a transferrin saturation of lessthan 20%, dosing with the follistatin fusion protein is reduced, delayedor terminated.
 12. The method of claim 1, wherein if the patient has aferritin level of less than 100 ng/ml, dosing with the follistatinfusion protein is reduced, delayed or terminated.
 13. The method ofclaim 1, wherein if the patient has iron stores that are lower than thenormal range for patients of similar age and sex, the patient is treatedwith an iron supplement prior to dosing with the follistatin fusionprotein.
 14. The method of claim 1, wherein if the patient has atransferrin saturation of less than 20%, the patient is treated with aniron supplement prior to dosing with the activin-follistatin fusionprotein.
 15. The method of claim 1, wherein if the patient has aferritin level of less than 100 ng/ml, the patient is treated with aniron supplement prior to dosing with the follistatin fusion protein.16-18. (canceled)
 19. A method for dosing a patient with follistatinfusion protein, the method comprising dosing the patient in amounts andat intervals selected so as to reduce the risk of causing a rise inhemoglobin levels greater than 1 g/dl in two weeks.
 20. The method ofclaim 1 or claim 19, wherein the patient is suffering from anemia, abone-related disorder, cancer, or a disorder associated with muscle lossor insufficient muscle growth.
 21. The method of claim 1 or claim 19,wherein the patient is in need of bone growth, increased bone density orincreased bone strength. 22-23. (canceled)
 24. The method of claim 20,wherein the patient has breast cancer. 25-45. (canceled)
 46. The methodof claim 1, wherein the follistatin fusion protein comprises a firstamino acid sequence and a second amino acid sequence, wherein the firstamino acid sequence comprises a sequence that is at least 90% identicalto SEQ ID NO: 17 or that is at least 90% identical to a mature form ofSEQ ID NO: 17, and wherein the second amino acid sequence comprises animmunoglobulin Fc domain; wherein the fusion protein comprises a linkerbetween the first amino acid sequence and the second amino acidsequence; and wherein the linker comprises three glycines.